By Counterforce Health Team in Chenodal (chenodiol) —

How to Get Chenodal (Chenodiol) Covered by Blue Cross Blue Shield in New York: Complete PA Guide with Appeals Process

Answer Box: Getting Chenodal Covered by Blue Cross Blue Shield in New York

Fastest path to approval: Submit prior authorization through your BCBS provider portal with imaging showing radiolucent gallstones, documentation of surgical contraindications, and evidence of failed ursodiol therapy. If denied, file an internal appeal within 60 days, then request external review through NY Department of Financial Services within 4 months. Start today: Call BCBS member services at the number on your insurance card to confirm your specialty pharmacy network and download the current PA form.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all BCBS plans BCBS Provider Portal
Specialty Pharmacy Must use in-network specialty pharmacy Member services or formulary documents
Step Therapy 6-month ursodiol trial required first PA form and medical policy
Imaging Documentation Radiolucent stones in functioning gallbladder Ultrasound or CT reports
Surgical Assessment Documentation of surgical contraindications Provider letter with risk assessment
Liver Monitoring Baseline and ongoing LFTs required Lab results and monitoring plan

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Network Status

Who does it: Patient or clinic staff
Timeline: Same day
Call BCBS member services to confirm:

  • Your plan covers specialty medications
  • Which specialty pharmacies are in-network
  • Current PA form requirements

2. Gather Required Documentation

Who does it: Clinical team
Timeline: 1-2 weeks
Collect:

  • Imaging reports explicitly stating "radiolucent" or "non-calcified" gallstones
  • Documentation of gallbladder function (oral cholecystography preferred)
  • Records of ursodiol trial with dates, doses, and outcomes
  • Surgical risk assessment from treating physician
  • Baseline liver function tests

3. Complete Prior Authorization Request

Who does it: Prescribing provider
Timeline: 3-5 business days
Submit through BCBS provider portal with:

  • Completed PA form
  • Medical necessity letter addressing each coverage criterion
  • All supporting documentation
  • Patient insurance information

4. Track Decision and Prepare for Denial

Who does it: Clinic staff
Timeline: 7-14 business days
BCBS typically responds within 72 hours for urgent requests, 14 days for standard. If approved, coordinate with specialty pharmacy. If denied, immediately request denial letter with specific reasons.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
"Ursodiol not tried first" Submit pharmacy claims showing 6-month trial at 8-10 mg/kg/day or contraindication documentation
"Not medically necessary" Provide surgical risk assessment and guidelines supporting non-surgical management
"Experimental/investigational" Reference FDA approval and established use in gastroenterology guidelines
"Non-formulary drug" Request formulary exception with failed alternative therapy documentation
"Quantity limits exceeded" Submit dosing rationale based on weight and clinical response

Appeals Process for New York BCBS Patients

Internal Appeal (First Level)

  • Deadline: 60 days from denial letter
  • How to file: BCBS member portal or written request
  • Required documents: Denial letter, additional clinical evidence, provider letter
  • Timeline: 30 days for standard, 72 hours for urgent

External Review Through NY Department of Financial Services

  • Deadline: 4 months from final internal denial
  • How to file: NY DFS External Appeal Portal
  • Cost: $25 (waived for financial hardship)
  • Timeline: 30 days standard, 72 hours urgent
  • Binding decision: Yes, insurer must comply if overturned
From our advocates: We've seen Chenodal appeals succeed when providers clearly document why surgery isn't appropriate and include specific details about failed ursodiol therapy. The key is addressing each coverage criterion point-by-point rather than making general medical necessity arguments.

Cost Assistance and Specialty Pharmacy Requirements

Manufacturer Support Programs

Travere Therapeutics offers the CHENODAL Total Care Hub with:

  • Copay assistance: For commercially insured patients (excludes government insurance)
  • Patient assistance program: Income-based free drug program
  • Contact: 1-888-969-4343 (verify current number)

Specialty Pharmacy Coordination

Chenodal requires specialty pharmacy dispensing through BCBS networks. Key steps:

  1. Confirm in-network specialty pharmacy options
  2. Transfer prescription after PA approval
  3. Coordinate baseline lab monitoring
  4. Schedule follow-up imaging at 6-12 months

Counterforce Health helps patients and providers navigate complex prior authorization requirements by analyzing denial letters and crafting targeted appeals with the right clinical evidence and payer-specific documentation.

Scripts for Calling Your Insurance

Initial Coverage Verification Script

"Hi, I'm calling to verify coverage for Chenodal, spelled C-H-E-N-O-D-A-L, for policy number [X]. Can you tell me:

  • Is prior authorization required?
  • Which specialty pharmacies are in my network?
  • What's the current PA form I need?
  • Are there any step therapy requirements?"

Appeal Status Check Script

"I'm calling about my appeal for Chenodal denial, reference number [X]. Can you tell me:

  • What's the current status?
  • When will I receive a decision?
  • What additional information might help my case?
  • How do I request expedited review if this becomes urgent?"

When to Escalate to New York State Regulators

Contact the NY Department of Financial Services if:

  • BCBS violates appeal deadlines (30 days internal, 72 hours urgent)
  • You're denied access to external review
  • The plan doesn't comply with an external review decision
  • You experience procedural violations during the appeals process

New York also has Community Health Advocates at 888-614-5400 for free assistance with insurance appeals.

FAQ: Common Questions

How long does BCBS PA take in New York?
Standard requests: 14 days. Urgent requests: 72 hours. Track status through the provider portal or member services.

What if Chenodal is non-formulary on my plan?
Request a formulary exception with documentation of failed formulary alternatives (ursodiol) and medical necessity for non-formulary therapy.

Can I request expedited review?
Yes, if delay would seriously jeopardize your health. Your provider must attest to urgency in writing.

Does step therapy apply if I failed ursodiol outside New York?
Yes, but you can use out-of-state medical records. Ensure documentation includes dates, doses, duration, and specific reasons for discontinuation.

What happens if my appeal is denied?
You can request external review through NY DFS within 4 months. This is an independent medical review that's binding on BCBS.

How much does Chenodal cost without insurance?
Brand pricing varies by strength and pharmacy. Contact Travere's Total Care Hub for current pricing and assistance options.

Checklist: What to Gather Before You Start

Before submitting your PA request, collect:

  • Insurance card (front and back copies)
  • Complete medical records related to gallstone diagnosis
  • Imaging reports (ultrasound, CT, or oral cholecystography)
  • Documentation of ursodiol trial or contraindications
  • Surgical consultation notes or risk assessment
  • Current liver function tests
  • List of all medications and allergies
  • Previous denial letters (if any)

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about your specific medical situation and treatment options.

Sources & Further Reading

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