By Counterforce Health Team in Cresemba (isavuconazole) —

How to Get Cresemba (Isavuconazole) Covered by Blue Cross Blue Shield in California: Prior Authorization Forms, Appeals & Timelines

Answer Box: Getting Cresemba Covered by Blue Cross Blue Shield in California

Blue Cross Blue Shield California requires prior authorization for all Cresemba (isavuconazole) requests. Submit clinical documentation showing confirmed invasive aspergillosis or mucormycosis (ICD-10 codes B46.0-B46.9) via AuthAccel portal or fax. If denied, file an internal appeal within 60 days, then request California's Independent Medical Review (IMR) through DMHC. Success rate: 68.6% of Blue Cross denials overturned by IMR in 2023.

First step today: Gather your diagnosis, prior treatment records, and insurance card. Have your doctor submit PA request with medical necessity documentation.

Table of Contents

  1. Blue Cross Blue Shield Plan Types in California
  2. Cresemba Formulary Status & Tiers
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Requirements
  5. Cost-Share Considerations
  6. Submission Process & Forms
  7. Appeals Process in California
  8. Common Denial Reasons & Solutions
  9. When to Escalate to State Review
  10. FAQ

Blue Cross Blue Shield Plan Types in California

California has two main Blue Cross organizations serving different markets:

Blue Shield of California covers individual, small group, and large employer plans, plus Medi-Cal (Blue Shield Promise). Anthem Blue Cross operates separately, serving commercial and Medicare Advantage members.

Key differences for Cresemba coverage:

  • HMO plans: Require referrals to infectious disease specialists; prior authorization processed through medical benefit
  • PPO/EPO plans: Direct specialist access; may route through pharmacy or medical benefit depending on administration site
  • Medi-Cal (Blue Shield Promise): Pharmacy requests via fax only; verify current PA list
Note: Both organizations require prior authorization for Cresemba regardless of plan type.

Cresemba Formulary Status & Tiers

Coverage Status: Cresemba (isavuconazonium sulfate) is covered under the medical benefit for both Blue Shield and Anthem Blue Cross California plans, requiring prior authorization before administration.

Coverage at a Glance

Requirement Blue Shield CA Anthem Blue Cross CA Source
Prior Authorization Required for all uses Required (verify plan-specific) Blue Shield Policy
Formulary Tier Medical benefit Varies by formulary Anthem Drug Lists
Step Therapy Not specified May apply (verify) Plan-specific
Quantity Limits Per clinical review Per clinical review Policy documents
Age Restrictions Per FDA label Per FDA label FDA prescribing info

Alternative agents that may be preferred include voriconazole (first-line for invasive aspergillosis) and liposomal amphotericin B (first-line for mucormycosis).

Prior Authorization Requirements

Medical Necessity Criteria

Blue Shield of California requires documentation of:

  1. Confirmed diagnosis with ICD-10 codes B46.0-B46.5, B46.8, or B46.9 (invasive aspergillosis or mucormycosis)
  2. Clinical evidence supporting invasive fungal infection
  3. Initial authorization covers up to 3 months of therapy
  4. Continuation requests require reassessment for efficacy

Required Documentation

For initial requests:

  • Pathology/culture results confirming invasive fungal infection
  • Imaging studies (CT, MRI) showing characteristic findings
  • Infectious disease consultation notes (may be required)
  • Medical rationale if voriconazole cannot be used (drug interactions, QT prolongation risk, prior failure)

For continuation:

  • Clinical response documentation
  • Reason oral formulation cannot be used (if requesting IV continuation)
  • Updated imaging or laboratory monitoring
Clinician Corner: Include specific contraindications to first-line agents. For aspergillosis, document why voriconazole is inappropriate (e.g., significant drug interactions with immunosuppressants, QT prolongation risk). For mucormycosis, if amphotericin B is contraindicated, cite renal dysfunction or prior nephrotoxicity.

Specialty Pharmacy Requirements

Blue Shield of California: Cresemba may be dispensed through designated specialty pharmacies for take-home oral formulations. IV formulations are typically provided through hospital or infusion center pharmacies.

Anthem Blue Cross: May require specialty pharmacy network (CarelonRx or BioPlus) for oral formulations. Verify with your specific plan.

Patient setup steps:

  1. Confirm your plan's specialty pharmacy network
  2. Transfer prescription to designated pharmacy
  3. Complete enrollment and insurance verification
  4. Arrange delivery or pickup scheduling

Cost-Share Considerations

Cresemba costs vary significantly based on your plan's benefit structure:

Typical scenarios:

  • Medical benefit: Subject to deductible, then coinsurance (often 20-30% for specialty medications)
  • Pharmacy benefit: Higher tier copay ($100-500+ per fill)
  • Hospital/infusion: Usually medical benefit with facility fees

Financial assistance options:

Tip: Request a pre-authorization cost estimate from your plan before starting treatment to understand your out-of-pocket responsibility.

Submission Process & Forms

Step-by-Step: Fastest Path to Approval

  1. Gather documentation (patient): Insurance card, prior treatment records, diagnostic results
  2. Submit PA request (provider): Use AuthAccel portal or download Cresemba-specific form
  3. Include clinical notes (provider): Diagnosis confirmation, prior therapy failures, contraindications to alternatives
  4. Track status (provider/patient): Monitor via AuthAccel or call provider services
  5. Respond to requests (provider): Submit additional information within specified timeframes
  6. Receive determination (all): Typically within 5-15 business days for standard requests
  7. Begin treatment (patient): If approved, coordinate with specialty pharmacy or infusion center

Submission Channels

Method Blue Shield CA Timeline Notes
AuthAccel (online) Provider portal Fastest processing Preferred method
CoverMyMeds Electronic PA 1-3 business days Alternative e-submission
Fax Download forms from portal 3-5 business days Include all documentation

Appeals Process in California

Internal Appeal (First Level)

Timeline: File within 60 calendar days of denial notice Response time: 30 calendar days for standard appeals, 72 hours for expedited Required: Denial letter, supporting clinical documentation, appeal request form

California Independent Medical Review (IMR)

If your internal appeal is denied, California offers powerful external review rights:

Success rates: In 2023, 68.6% of Anthem Blue Cross medical necessity denials were overturned by DMHC Independent Medical Review.

Process:

  1. File internal appeal first (required step)
  2. Wait for denial or 30-day response deadline
  3. Request IMR through DMHC Help Center (888-466-2219)
  4. Submit evidence supporting medical necessity
  5. Receive decision within 45 days (expedited: 7 days)

Cost: Free to patients - no filing fees

Important: IMR decisions are binding on your health plan. If the independent physicians determine Cresemba is medically necessary, your plan must authorize coverage.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Provide guidelines showing Cresemba as appropriate therapy IDSA guidelines, FDA labeling, specialist consultation
"Experimental/investigational" Cite FDA approval and established use FDA approval letter, published treatment protocols
"Step therapy not completed" Document contraindications to first-line agents Drug interaction studies, prior adverse reactions
"Insufficient clinical information" Submit complete medical records Pathology reports, imaging, ID consult notes
"Diagnosis not supported" Provide definitive diagnostic evidence Culture results, biopsy reports, radiologic findings

Scripts for Common Situations

Patient calling Blue Shield: "I'm calling about a prior authorization denial for Cresemba, reference number [X]. My doctor says this medication is medically necessary for my invasive fungal infection. Can you tell me exactly what additional information is needed for approval?"

Provider requesting peer-to-peer: "I'm requesting a peer-to-peer review for my patient's Cresemba denial. The patient has confirmed invasive aspergillosis with contraindications to voriconazole due to significant drug interactions. When can we schedule this clinical discussion?"

When to Escalate to State Review

Contact California regulators if your health plan:

  • Fails to respond to appeals within required timeframes
  • Denies IMR requests inappropriately
  • Creates unreasonable barriers to care

DMHC Help Center: 888-466-2219 for HMO and most PPO plans California Department of Insurance: 800-927-4357 for other health policies

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed responses. Their platform identifies the specific denial basis and drafts point-by-point rebuttals aligned with each plan's own rules, incorporating the right clinical evidence and procedural requirements to maximize approval chances.

FAQ

How long does Blue Cross Blue Shield PA take in California? Standard prior authorizations typically take 5-15 business days. Expedited requests (for urgent medical situations) must be processed within 72 hours.

What if Cresemba is non-formulary on my plan? Request a formulary exception with medical necessity documentation. Emphasize contraindications to preferred alternatives and cite clinical guidelines supporting Cresemba use.

Can I request an expedited appeal? Yes, if there's an imminent and serious threat to your health. Expedited appeals must be decided within 72 hours by your health plan.

Does step therapy apply if I've failed treatments outside California? Medical records from other states are generally accepted. Provide documentation of prior therapy failures, including dates, doses, and reasons for discontinuation.

What happens if my doctor isn't in-network? Out-of-network providers can still submit prior authorizations, but you may face higher cost-sharing. Consider requesting a network adequacy exception if no in-network infectious disease specialists are available.

How do I find my plan's specific formulary? Blue Shield members can search at blueshieldca.com/formulary. Anthem members should check anthem.com/ca/pharmacy-information/drug-list-formulary.

What if I'm switching from another Blue Cross plan? California plans generally honor prior authorizations from other Blue plans for 90 days during transitions, but verify this with your new plan's member services.

Can I appeal while continuing treatment? For urgent situations, request expedited processing and ask your doctor about interim coverage options. Some plans provide temporary approvals pending appeal resolution.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and procedures may change. Always verify current requirements with your health plan and consult your healthcare provider for medical decisions. For personalized assistance with complex appeals, Counterforce Health offers specialized support in converting insurance denials into successful prior authorizations and appeals.

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