By Counterforce Health Team in Cerezyme (imiglucerase) —

How to Get Cerezyme (Imiglucerase) Covered by Blue Cross Blue Shield of Michigan: 2024 PA Requirements, Appeals Process & Forms

Answer Box: Getting Cerezyme Covered by Blue Cross Blue Shield of Michigan

Good news for Michigan patients: Blue Cross Blue Shield of Michigan (BCBSM) covers Cerezyme as its preferred enzyme replacement therapy for Type 1 Gaucher disease. As of January 1, 2024, no prior authorization is required for Medicare Advantage members. Commercial members may need to submit a medication authorization request form, but routine PA barriers have been largely removed.

Your fastest path to approval:

  1. Confirm your BCBSM plan type (Medicare Advantage vs. commercial)
  2. Have your physician document your Gaucher disease diagnosis with enzyme testing and genetic confirmation
  3. For commercial plans, submit the Medication Authorization Request Form if requested

Start today: Call BCBSM Medical Drug Helpdesk at 1-800-437-3803 to verify your specific coverage requirements.

Table of Contents

  1. Plan Types & Coverage Implications
  2. Formulary Status & Tier Placement
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Network Rules
  5. Cost-Share Basics
  6. Submission Process & Forms
  7. Common Approval Patterns
  8. Appeals Process for Michigan
  9. Cost Assistance Programs
  10. FAQ

Plan Types & Coverage Implications

Blue Cross Blue Shield of Michigan offers several plan types, and your coverage for Cerezyme depends on which one you have:

Medicare Advantage (Medicare Plus Blue & BCN Advantage)

  • Cerezyme is covered under the medical benefit (not pharmacy)
  • No prior authorization required as of January 1, 2024
  • Step therapy only applies to alternative ERTs—if your doctor wants to switch you from Cerezyme to VPRIV or Elelyso, that would require step therapy documentation

Commercial Plans (Traditional, PPO, HMO)

  • Prior authorization may be required but has been streamlined for 2024
  • Coverage typically falls under specialty pharmacy benefits
  • Must use in-network providers for administration
Note: Starting January 1, 2026, many commercial members with Exclusive Specialty Network (ESN) plans will need to fill Cerezyme through Walgreens Specialty Pharmacy exclusively.

Formulary Status & Tier Placement

Cerezyme holds preferred status on BCBSM formularies for Gaucher disease treatment. Here's what this means:

Coverage Aspect Status Impact
Formulary inclusion Preferred ERT Lower cost-sharing than alternatives
Step therapy Required for alternatives only Cerezyme is first-line; no steps needed
Quantity limits Standard dosing allowed 2.5-60 U/kg per dosing guidelines
Site of care Provider-administered Covered under medical benefit

Alternative ERTs like VPRIV and Elelyso require step therapy documentation showing Cerezyme trial first, unless contraindicated.

Prior Authorization Requirements

What's Changed in 2024

BCBSM significantly streamlined Cerezyme authorization:

  • Medicare Advantage: No PA required since January 1, 2024
  • Commercial plans: Simplified authorization process with reduced barriers

When PA Is Still Required

You'll need prior authorization if:

  • Requesting dosing outside FDA-approved ranges
  • Switching between ERT medications
  • Using Cerezyme for off-label indications
  • Your plan specifically requires it (check your benefits)

Required Documentation

When PA is needed, your physician must provide:

  • Diagnostic confirmation: Both enzyme testing (low glucocerebrosidase activity) and genetic testing (biallelic GBA1 pathogenic variants)
  • Clinical justification: Symptoms requiring treatment, treatment goals
  • Dosing rationale: Weight-based calculations, frequency
  • Prior therapy history: If switching from another ERT

Specialty Pharmacy Network Rules

Current Requirements (2024-2025)

Most BCBSM members can use their preferred specialty pharmacy for Cerezyme, but this is changing.

Coming Changes (January 2026)

Members with Exclusive Specialty Network plans must use:

  • Walgreens Specialty Pharmacy for home delivery
  • Participating Walgreens retail locations for pickup

Action needed: If you're affected by ESN changes, your prescriber must send new prescriptions to:

  • Phone: 1-866-515-1355
  • Fax: 1-866-515-1356
  • E-prescribing: Select "Walgreens Specialty Pharmacy – MICHIGAN"
Important: Failure to use the required network pharmacy when ESN applies will result in full out-of-pocket costs.

Cost-Share Basics

Your out-of-pocket costs depend on several factors:

Medicare Advantage Plans

  • Typically covered under Part B medical benefit
  • 20% coinsurance after deductible (if applicable)
  • Annual out-of-pocket maximums apply

Commercial Plans

  • Varies by specific plan design
  • May have specialty drug copays or coinsurance
  • Deductible may apply before coverage begins

Cost example: With Cerezyme's approximate cost of $1,700+ per 400-unit vial, even small coinsurance percentages can add up quickly.

Submission Process & Forms

For Medicare Advantage Members

No submission typically required—coverage is automatic for appropriate dosing.

For Commercial Members

Submit the Medication Authorization Request Form via:

  • Fax: 1-877-325-5979
  • Online: Through Availity provider portal
  • Processing time: 5-7 business days standard, 24-48 hours expedited

Required Form Fields

  • Patient demographics and insurance information
  • Prescriber information and credentials
  • Diagnosis: Type 1 Gaucher disease with ICD-10 code
  • Clinical justification: Enzyme levels, genetic testing results
  • Dosing details: Units per kilogram, frequency, administration site

Common Approval Patterns

Successful Cerezyme requests typically include:

Strong Clinical Documentation

  • Enzyme activity results showing deficiency
  • Genetic testing confirming GBA1 mutations
  • Symptom documentation (anemia, thrombocytopenia, hepatosplenomegaly, bone involvement)
  • Treatment goals and monitoring plan

Complete Administrative Details

  • Correct ICD-10 codes for Gaucher disease
  • Appropriate HCPCS/J-codes for billing
  • Clear administration site (infusion center, hospital outpatient)
  • Prescriber specialty (hematology, genetics, internal medicine)
From our advocates: We've seen the strongest approvals come from requests that clearly connect the patient's specific symptoms to established treatment goals. Don't just state the diagnosis—explain why this patient needs treatment now and how you'll measure success.

Appeals Process for Michigan

If BCBSM denies your Cerezyme request, Michigan law provides robust appeal rights:

Internal Appeals (First Level)

  • Timeline: File within 180 days of denial
  • Process: Submit through BCBSM member portal or by phone
  • Decision deadline: 30 days for standard, 72 hours for expedited
  • Required: Copy of denial letter, supporting clinical documentation

External Review (Final Level)

Michigan's Department of Insurance and Financial Services (DIFS) offers independent review:

  • Timeline: File within 127 days of final internal denial
  • Process: DIFS External Review Request form online, email, fax, or mail
  • Decision deadline: 60 days standard, 72 hours expedited
  • Cost: Free to patients
  • Binding: Yes—if approved, BCBSM must cover

Contact DIFS: 877-999-6442 for questions about the external review process.

When to Request Expedited Appeals

  • Delay would seriously jeopardize your health
  • You're currently on Cerezyme and facing interruption
  • Your doctor provides a letter stating urgency

Cost Assistance Programs

Manufacturer Support

Sanofi offers Cerezyme Access and Copay Assistance for eligible patients:

  • Commercial insurance copay support
  • Patient assistance programs for uninsured/underinsured
  • Dedicated case management

Foundation Grants

  • National Organization for Rare Disorders (NORD): Medication assistance
  • HealthWell Foundation: Disease-specific grants
  • Patient Access Network Foundation: Specialty drug support

State Resources

Michigan residents may qualify for additional programs through the state's Medicaid expansion or pharmaceutical assistance programs.

Frequently Asked Questions

How long does BCBSM prior authorization take?

Standard requests: 5-7 business days. Expedited requests (when medically urgent): 24-48 hours. Medicare Advantage members typically don't need PA for Cerezyme as of 2024.

What if Cerezyme is denied?

File an internal appeal first, then request external review through Michigan DIFS if still denied. You have 127 days from the final internal denial to file for external review.

Can I get expedited coverage?

Yes, if delay would harm your health. Your doctor must provide a letter explaining the medical urgency. Expedited appeals are decided within 72 hours.

Does step therapy apply to Cerezyme?

No—Cerezyme is BCBSM's preferred ERT. Step therapy only applies if your doctor wants to switch you to alternatives like VPRIV or Elelyso.

What if I'm switching from another ERT?

You may need to provide documentation of your response to the previous therapy, any side effects, or clinical reasons for the switch.

Will I need to use Walgreens Specialty Pharmacy?

Starting January 1, 2026, members with Exclusive Specialty Network plans must use Walgreens for self-administered specialty drugs. Check with BCBSM to see if this affects you.

When to Get Help

Consider professional assistance if you're facing:

  • Repeated denials despite complete documentation
  • Complex appeal situations involving multiple therapies
  • Urgent medical needs requiring expedited review

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to create point-by-point rebuttals aligned to each payer's specific requirements, helping patients, clinicians, and specialty pharmacies navigate complex coverage decisions more effectively.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently—always verify current requirements with Blue Cross Blue Shield of Michigan directly. For questions about your specific situation, consult your healthcare provider and contact BCBSM member services.

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