By Counterforce Health Team in Arikayce (amikacin liposome inhalation) —

How to Get Arikayce Covered by Blue Cross Blue Shield in Washington: Complete Guide to Prior Authorization, Appeals, and State Review

Answer Box: Getting Arikayce Covered by Blue Cross Blue Shield in Washington

Arikayce (amikacin liposome inhalation) requires prior authorization from Blue Cross Blue Shield plans in Washington for refractory MAC lung disease. You need documented failure of at least 6 months of standard multidrug therapy with persistent positive cultures. The fastest path: have your provider submit a complete prior authorization request through the Availity portal with all required clinical documentation. If denied, Washington's strong external review process through certified Independent Review Organizations (IROs) can overturn decisions. Start by verifying your specific BCBS plan (Premera Blue Cross or Regence BlueShield) and gathering your MAC treatment history.

First step today: Call the member services number on your insurance card to confirm your plan's specialty drug requirements and request the current Arikayce prior authorization form.

Table of Contents

  1. Coverage at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Required Forms and Documentation
  4. Submission Portals and Methods
  5. Common Denial Reasons and Solutions
  6. Appeals Process for Washington BCBS
  7. Specialty Pharmacy Network
  8. Support Contacts and Resources
  9. Washington State External Review
  10. Cost Assistance Programs
  11. FAQ

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all BCBS plans Plan formulary or member portal Premera PA Requirements
Formulary Tier Typically Tier 4 specialty Check plan's drug list BCBS Specialty Guidelines
Age Requirement Adults ≥18 years FDA labeling FDA Arikayce Label
Indication Refractory MAC lung disease only Clinical documentation ATS/IDSA Guidelines
Prior Therapy ≥6 months failed standard treatment Medical records required Clinical Criteria
Combination Therapy Must be part of multidrug regimen Prescription documentation FDA Requirements
Appeals Deadline 180 days from denial Plan documents Washington IRO Process

Step-by-Step: Fastest Path to Approval

1. Verify Your Specific BCBS Plan

Who does it: Patient
Document needed: Insurance card
How to submit: Phone call
Timeline: Same day
Call the member services number on your card to confirm whether you have Premera Blue Cross or Regence BlueShield, as requirements may vary slightly between Washington's BCBS carriers.

2. Gather Complete MAC Treatment History

Who does it: Patient and provider
Documents needed: Medical records, culture results, prescription history
Timeline: 1-3 days
Collect documentation of your MAC diagnosis, all treatments tried for at least 6 months, culture results showing persistent infection, and current combination therapy plan.

3. Provider Submits Prior Authorization

Who does it: Prescribing physician
How to submit: Availity provider portal or fax
Timeline: 3-5 business days for decision
Your provider completes the BCBS prior authorization form with all clinical documentation and submits through the secure portal.

4. Monitor Authorization Status

Who does it: Patient or provider
How to check: Provider portal or phone
Timeline: Check after 3 days
Track the request status and be prepared to provide additional documentation if requested.

5. If Approved: Coordinate Specialty Pharmacy

Who does it: Patient and provider
Timeline: 1-2 days
Work with your provider to send the prescription to an in-network specialty pharmacy like Accredo or CVS Specialty.

6. If Denied: File Internal Appeal

Who does it: Patient or provider
Timeline: Within 180 days of denial
Submit additional clinical evidence and medical necessity documentation through the appeals process.

7. If Still Denied: Request External Review

Who does it: Patient
How to submit: Through BCBS or directly to Washington OIC
Timeline: Decision within 30 days
Washington's Independent Review Organization process provides binding external review by medical specialists.

Required Forms and Documentation

Clinical Documentation Checklist

  • MAC Diagnosis Confirmation: Chest imaging, sputum cultures, ATS/IDSA criteria documentation
  • Treatment History: Complete record of at least 6 months of guideline-based multidrug therapy
  • Refractory Evidence: At least two positive sputum cultures after 6+ months of treatment
  • Current Regimen: Documentation that Arikayce will be used in combination, not as monotherapy
  • Prescriber Attestation: Specialist (preferably pulmonologist or infectious disease) statement of medical necessity

Required Forms by Plan

Premera Blue Cross: Access current forms through the provider portal or request via fax
Regence BlueShield: Similar requirements; verify specific forms with provider services

Tip: Incomplete documentation is the most common reason for delays. Ensure all culture dates, medication trials, and specialist notes are clearly documented before submission.

Submission Portals and Methods

Electronic Submission (Preferred)

  • Availity Provider Portal: Primary method for most Washington BCBS plans
  • Interactive Care Reviewer (ICR): Alternative portal for some providers
  • Processing Time: 3-5 business days standard, 24-72 hours expedited

Fax Submission

  • Prior Authorization Fax: 844-512-7020 (verify current number)
  • Cover Sheet Requirements: Patient ID, provider NPI, urgency level, page count
  • Confirmation: Always request fax confirmation receipt

Specialty Pharmacy Coordination

Once approved, prescriptions typically go to:

  • Accredo: 1-833-721-1619 (provider support)
  • CVS Specialty: 1-800-237-2767
  • BioPlus Specialty: 1-866-514-8082

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
Insufficient prior therapy Provide complete treatment timeline Pharmacy records, prescription history, chart notes
Missing culture results Submit all positive cultures Lab reports with dates and organism identification
Off-label use Demonstrate refractory indication Specialist consultation notes, guideline references
Lack of combination therapy Show concurrent medications Current prescription list, treatment plan
Missing specialist evaluation Obtain pulmonology/ID consultation Specialist assessment and recommendation

Appeals Process for Washington BCBS

Internal Appeals (First Level)

  • Timeline: File within 180 days of denial
  • Decision Time: 30 days standard, 72 hours expedited
  • Required: Additional clinical evidence, medical necessity letter
  • Submission: Same portal/fax as original PA

Internal Appeals (Second Level)

  • Timeline: 60 days from first-level denial
  • Review: Independent medical review within BCBS
  • Outcome: Final internal decision

External Review (Washington State)

Washington provides one of the strongest external review processes in the nation:

  • Eligibility: After exhausting internal appeals
  • Timeline: Request within 180 days of final internal denial
  • Process: Automatic assignment to certified IRO specialist
  • Decision Time: 30 days standard, 72 hours expedited
  • Binding: IRO decision is binding on BCBS
  • Cost: No cost to patient
Note: As of 2025, Washington automatically forwards denied appeals to external review unless you opt out, significantly improving patient access to independent medical review.

Specialty Pharmacy Network

In-Network Options

Most Washington BCBS plans contract with these specialty pharmacies for Arikayce:

Accredo (Most Common)

  • Provider phone: 1-833-721-1619
  • Patient services: Check your member portal
  • Prescription fax: 1-800-246-7302

CVS Specialty

  • Provider phone: 1-800-237-2767
  • Prescription fax: 1-800-323-2445

BioPlus Specialty

  • Provider phone: 1-866-514-8082
  • Prescription fax: 1-866-203-9160

Transfer Process

  1. Confirm in-network status with your specific plan
  2. Provider sends prescription and PA approval
  3. Specialty pharmacy coordinates delivery and monitoring
  4. Patient receives medication training and support

Support Contacts and Resources

Member Support

  • Premera Blue Cross: Member services number on your ID card
  • Regence BlueShield: Member services number on your ID card
  • Questions to Ask: Current PA requirements, specialty pharmacy options, appeals timeline

Provider Support

  • Clinical Review: Peer-to-peer review available for complex cases
  • PA Status: Check through provider portal or dedicated phone lines
  • Appeals Assistance: Clinical documentation support available

Washington State Resources

  • Office of Insurance Commissioner: 1-800-562-6900
  • Consumer Advocacy: Free assistance with appeals and complaints
  • External Review: IRO process guidance

When dealing with insurance challenges, Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals that align with each plan's specific criteria.

Washington State External Review

Washington's external review process is particularly robust for specialty medications:

Key Features

  • Specialist Reviewers: IRO must assign reviewers with relevant clinical expertise
  • Binding Decisions: Insurers must comply with IRO determinations
  • No Patient Cost: State covers all external review expenses
  • Transparency: Patients receive copies of all materials sent to IRO

Process Steps

  1. Request External Review: Submit through BCBS or directly to OIC
  2. IRO Assignment: State automatically assigns certified reviewer
  3. Submit Evidence: 5 business days to provide additional documentation
  4. Review Period: IRO has 30 days for standard review
  5. Decision: Binding determination with written rationale

Success Factors

  • Complete clinical documentation
  • Specialist support letters
  • Guideline references (ATS/IDSA/ERS)
  • Evidence of medical necessity

Cost Assistance Programs

Manufacturer Support

InLighten Patient Support Program

Foundation Resources

  • Patient Access Network Foundation
  • Good Days (chronic disease assistance)
  • HealthWell Foundation
  • State pharmaceutical assistance programs

FAQ

How long does BCBS prior authorization take in Washington? Standard reviews take 3-5 business days. Expedited reviews for urgent medical needs are completed within 24-72 hours. Always request expedited review if delaying treatment could harm your health.

What if Arikayce is non-formulary on my plan? You can request a formulary exception through the same prior authorization process. Provide documentation showing why formulary alternatives are inappropriate or have failed.

Can I request an expedited appeal? Yes, if your health could be seriously harmed by delays. Mark all requests as expedited and provide supporting clinical documentation from your physician.

Does step therapy apply if I've already failed treatments outside Washington? Treatment history from other states typically counts toward step therapy requirements. Provide complete documentation of all prior therapies, regardless of where they were tried.

What happens if my appeal is denied? Washington's external review process provides a final opportunity for independent medical specialists to review your case. This decision is binding on your insurance company.

How do I know if I have Premera or Regence? Check your insurance card or call the member services number. Both are BCBS plans in Washington but may have slightly different procedures.

Can my primary care doctor prescribe Arikayce? While technically possible, specialist evaluation (pulmonology or infectious disease) significantly improves approval chances and is often required by insurance plans.

What if I can't afford the copay even with insurance? The manufacturer's InLighten program offers copay assistance, and several patient foundations provide grants for specialty medications. Apply early as funding is limited.

For complex denials or appeals, Counterforce Health helps patients and providers navigate insurance challenges by creating evidence-based appeals that address specific payer criteria and regulatory requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific guidance. Coverage policies and procedures may change; verify current requirements with your insurer.

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