By Counterforce Health Team in Cresemba (isavuconazole) —

How to Get Cresemba (Isavuconazole) Covered by Blue Cross Blue Shield in Virginia: Complete Prior Authorization and Appeals Guide

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

Blue Cross Blue Shield Virginia (Anthem) requires prior authorization for Cresemba (isavuconazole), with approval typically taking 5-15 business days. Your fastest path: (1) Verify your plan's specialty pharmacy network and formulary tier, (2) Have your doctor submit a prior authorization request through Availity or by calling 800-901-0020, and (3) Include complete documentation of invasive aspergillosis/mucormycosis diagnosis with ICD-10 codes B44.0-B44.7 or B46.0-B46.9. If denied, Virginia's Bureau of Insurance provides external review within 45 days, with expedited 72-hour reviews for urgent cases.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather What You Need
  4. Submit the Prior Authorization Request
  5. Follow-Up and Timeline
  6. If You're Asked for More Information
  7. If Your Request Is Denied
  8. Virginia External Review Process
  9. Costs and Patient Support
  10. Printable Checklist
  11. FAQ

What This Guide Covers

This guide helps patients with invasive aspergillosis or mucormycosis—and their healthcare teams—navigate Blue Cross Blue Shield Virginia's prior authorization process for Cresemba (isavuconazole). Whether you're facing an initial request or appealing a denial, you'll find step-by-step instructions, required forms, and Virginia-specific appeal rights.

Cresemba is a specialty antifungal medication that treats serious invasive mold infections. At approximately $394 per IV vial or $1,620 for a 14-day oral course, insurance coverage is essential for most patients. The good news: with proper documentation, most medically necessary requests get approved.

Who this helps: Patients with confirmed invasive aspergillosis or mucormycosis, their caregivers, and healthcare providers managing prior authorization requests in Virginia.

Before You Start: Verify Your Coverage

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Cresemba requests Anthem Provider Portal
Formulary Tier Specialty tier (varies by plan) Member ID card or plan documents
Specialty Pharmacy Must use in-network specialty pharmacy Contact Member Services
Diagnosis Codes ICD-10 B44.0-B44.7 or B46.0-B46.9 Medical records
Appeals Deadline 180 days for internal, 120 days for external Virginia Bureau of Insurance

Step 1: Confirm Your Plan Type

Blue Cross Blue Shield Virginia (operated by Anthem) covers different member types:

  • Commercial/Employer plans: Standard PA process applies
  • Individual/ACA marketplace: Same requirements as commercial
  • Medicare Advantage: May have additional step therapy requirements

Call the Member Services number on your ID card to confirm your specific plan's requirements.

Step 2: Check Specialty Pharmacy Network

Cresemba must be dispensed through an approved specialty pharmacy. Common in-network options for Anthem Virginia include:

  • Accredo Health Group
  • CVS Specialty
  • BioPlus Specialty Pharmacy

Verify your plan's current specialty pharmacy network before your doctor submits the prior authorization.

Gather What You Need

Clinical Documentation Checklist

Essential Medical Information:

  • Confirmed diagnosis with appropriate ICD-10 codes:
    • Invasive aspergillosis: B44.0 (invasive pulmonary), B44.7 (disseminated), B44.1 (other pulmonary), B44.2 (tonsillar)
    • Mucormycosis: B46.0 (rhinocerebral), B46.1 (pulmonary), B46.2 (gastrointestinal), B46.3 (cutaneous), B46.4 (disseminated), B46.5-B46.9 (other/unspecified)
  • Diagnostic evidence: Culture results, pathology reports, galactomannan/beta-D-glucan levels, imaging studies (CT, MRI)
  • Risk factors: Immunosuppression, diabetes, prolonged steroid use, neutropenia
  • Prior antifungal therapy: Documentation of treatments tried, failed, or contraindicated (especially voriconazole for aspergillosis)
  • Treatment plan: Proposed duration, loading dose schedule, monitoring plan

Required Forms and Submission Methods

For Providers:

  • Submit through Availity portal
  • Call Provider Services: 800-901-0020
  • Fax: Use the fax number provided in your Availity account (verify current number)
Tip: Infectious disease specialist involvement strengthens your request, as many payers prefer specialist oversight for invasive fungal infections.

Submit the Prior Authorization Request

Step-by-Step: Fastest Path to Approval

  1. Provider logs into Availity (or calls 800-901-0020)
  2. Complete prior authorization form with all required clinical details
  3. Attach supporting documentation: lab results, imaging, culture reports, specialist notes
  4. Specify specialty pharmacy for dispensing coordination
  5. Submit request and document confirmation number
  6. Follow up in 3-5 business days to check status
  7. Coordinate with specialty pharmacy once approved

Expected timeline: 5-15 business days for standard requests. Expedited reviews available for urgent cases.

Medical Necessity Letter Essentials

Your doctor's letter should address:

  • Clinical problem: Severity of invasive aspergillosis/mucormycosis
  • Prior treatments: What was tried first (amphotericin B, voriconazole) and why it failed or is contraindicated
  • Rationale for Cresemba: Why this specific antifungal is medically necessary
  • Supporting evidence: FDA approval, clinical guidelines, susceptibility testing
  • Treatment plan: Dosing, duration, monitoring
Clinician Corner: Reference the Infectious Diseases Society of America guidelines for invasive aspergillosis and mucormycosis to support your medical necessity argument. Include specific contraindications to first-line therapies when applicable.

Follow-Up and Timeline

What to Expect

Standard Review: 5-15 business days Expedited Review: 72 hours (requires clinical urgency documentation)

Sample Follow-Up Script

"Hi, I'm calling to check the status of a prior authorization request for Cresemba submitted on [date]. The confirmation number is [number]. Can you tell me if any additional information is needed?"

Document everything: reference numbers, representative names, dates, and any additional requests.

If You're Asked for More Information

Common requests include:

  • Additional lab work: Recent cultures, biomarker levels
  • Specialist consultation: ID physician evaluation and recommendations
  • Treatment history: Detailed records of prior antifungal failures
  • Imaging updates: Current CT/MRI showing infection progression

Response timeline: Usually 5-10 business days to submit additional information. Ask for the specific deadline when contacted.

If Your Request Is Denied

Common Denial Reasons & Solutions

Denial Reason How to Address
Insufficient documentation Submit complete culture results, imaging, specialist notes
Step therapy not met Document voriconazole failure, intolerance, or contraindication
Non-formulary status Request formulary exception with medical necessity letter
Experimental/investigational Provide FDA labeling and published guidelines supporting use

Internal Appeal Process

You have 180 days from the denial notice to file an internal appeal with Anthem Virginia.

Required steps:

  1. Submit written appeal with additional clinical documentation
  2. Include new evidence supporting medical necessity
  3. Request peer-to-peer review if available
  4. Document all communications

Virginia External Review Process

If your internal appeal is denied, Virginia law provides strong consumer protections through the Bureau of Insurance external review process.

Timeline and Process

Filing deadline: 120 days from final internal denial Review period: 45 days (standard) or 72 hours (expedited) Cost: Free to consumers

How to File

  1. Complete Form 216-A (External Review Request) from the Virginia Bureau of Insurance
  2. Submit to: Virginia Bureau of Insurance, Consumer Services Division
  3. Include: All denial letters, medical records, and supporting documentation
  4. Contact for guidance: 1-877-310-6560
Virginia Advantage: The state's external review process has helped many patients access specialty medications. Independent medical reviewers often overturn denials when clinical evidence supports medical necessity.

The Bureau assigns your case to an Independent Review Organization (IRO) with relevant medical expertise. You have 5 business days after case acceptance to submit additional information.

If approved by external review: Anthem must authorize coverage within 24-72 hours.

Costs and Patient Support

Manufacturer Support Programs

Astellas Pharma Support Solutions offers:

  • Copay assistance for eligible commercial patients
  • Patient access programs
  • Reimbursement support services

Additional Resources

  • Virginia Poverty Law Center: Free legal assistance for insurance appeals
  • Patient Advocate Foundation: Copay relief and case management
  • State pharmaceutical assistance programs: Check eligibility for Virginia residents

At Counterforce Health, we help patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed prior authorization requests and appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements, pulling the right clinical evidence and operational details that insurance companies expect to see.

Printable Checklist

Before Starting:

  • Verify Blue Cross Blue Shield Virginia plan type
  • Confirm specialty pharmacy network
  • Check formulary tier for Cresemba

Documentation to Gather:

  • ICD-10 diagnosis codes (B44.0-B44.7 or B46.0-B46.9)
  • Culture/pathology results confirming invasive infection
  • Imaging studies (CT, MRI)
  • Prior antifungal treatment records
  • Risk factors documentation
  • Specialist consultation notes

Submission Process:

  • Provider submits via Availity or calls 800-901-0020
  • Include medical necessity letter
  • Attach all supporting documentation
  • Document confirmation number
  • Follow up in 3-5 business days

If Denied:

  • File internal appeal within 180 days
  • Submit additional clinical evidence
  • Request peer-to-peer review
  • Consider Virginia external review if internal appeal fails

FAQ

How long does Blue Cross Blue Shield Virginia prior authorization take? Standard requests: 5-15 business days. Expedited reviews for urgent cases: up to 72 hours.

What if Cresemba is non-formulary on my plan? Request a formulary exception with a detailed medical necessity letter explaining why formulary alternatives are inappropriate.

Can I request an expedited appeal in Virginia? Yes. If waiting for standard review could seriously jeopardize your health, Virginia provides expedited external review within 72 hours.

Does step therapy apply if I failed voriconazole outside Virginia? Yes, but you must provide documentation of the failure or contraindication from your previous state's medical records.

What's the success rate for Cresemba appeals in Virginia? While specific statistics aren't published, Virginia's external review process has a strong track record of overturning wrongful denials when proper clinical evidence is provided.

Who pays for external review in Virginia? External review is free for consumers. The Bureau of Insurance covers all costs.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage processes and should not replace professional medical or legal advice. Coverage policies vary by individual plan. Always consult your healthcare provider about treatment decisions and contact your insurance company directly for plan-specific requirements. For assistance with complex appeals, consider consulting Counterforce Health or other patient advocacy services.

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