By Counterforce Health Team in Darzalex / Darzalex Faspro (daratumumab) —

How to Get Darzalex Covered by Blue Cross Blue Shield in Ohio: Prior Authorization Forms, Appeal Deadlines, and Success Strategies

Quick Answer: Getting Darzalex Covered by Ohio Blue Cross Blue Shield

Yes, Blue Cross Blue Shield covers Darzalex (daratumumab) in Ohio, but prior authorization is required. Anthem BCBS Ohio updated their clinical criteria (CC-0127) in December 2024 for both Darzalex IV and Darzalex Faspro. Your fastest path: Have your oncologist submit a PA request through the Anthem provider portal with documentation of your multiple myeloma diagnosis, prior treatments, and the specific FDA-approved regimen. Standard approvals take up to 72 hours; expedited reviews are available for urgent cases. If denied, you have 180 days to appeal and can request external review through the Ohio Department of Insurance.

Start today: Call the member services number on your insurance card to verify your specific plan's requirements and get the current PA form.

Table of Contents

  1. Why Ohio State Rules Matter for Your Darzalex Coverage
  2. Prior Authorization Requirements and Turnaround Times
  3. Step Therapy Protections in Ohio
  4. Continuity of Care During Plan Changes
  5. External Review and Complaints Process
  6. Practical Scripts for Calls and Appeals
  7. ERISA Plans and Federal vs. State Rules
  8. Quick Reference: Contacts and Resources

Why Ohio State Rules Matter for Your Darzalex Coverage

Ohio's insurance laws create important protections that work alongside Blue Cross Blue Shield's policies. Unlike some states, Ohio has specific requirements for how quickly insurers must respond to prior authorization requests and when they must grant step therapy exceptions.

For multiple myeloma patients, this matters because:

  • Ohio requires 48-hour responses for urgent PA requests (versus up to 14 days in some states)
  • Step therapy can be overridden if you've tried required drugs and failed
  • External review through the Ohio Department of Insurance provides an independent medical opinion

Your specific protections depend on your plan type. Fully insured plans (individual, small group, some large group) follow Ohio state law. Self-funded employer plans follow federal ERISA rules but often use similar processes.

Note: Check your Summary of Benefits or call member services to confirm whether your plan is state-regulated or self-funded.

Prior Authorization Requirements and Turnaround Times

Current Ohio BCBS Requirements (2024-2025)

Anthem Blue Cross Blue Shield Ohio requires prior authorization for all Darzalex formulations under their updated clinical criteria CC-0127, effective December 2, 2024.

Coverage Criteria Include:

  • Age ≥18 years
  • Confirmed multiple myeloma diagnosis
  • Use in FDA-approved combinations or NCCN-supported regimens
  • Documentation of transplant eligibility status
  • Prior therapy history for relapsed/refractory cases

Timeline Requirements

Request Type Ohio Deadline What Qualifies
Urgent/Expedited 48 hours Delay would seriously jeopardize health or cause severe pain
Standard 10 calendar days Non-urgent requests
Renewal Varies by plan Typically 6-12 months with response documentation

Deemed Approved Rule: If Anthem doesn't respond within these timeframes, your request is automatically approved under Ohio law.

Step-by-Step: Fastest Path to Approval

  1. Verify your plan type - Call member services to confirm PA requirements and current forms
  2. Gather documentation - Diagnosis, staging, prior treatments, performance status
  3. Prescriber submits PA - Via Anthem provider portal or fax with CC-0127 criteria
  4. Include FDA-approved regimen - Specify exact combination (e.g., Darzalex + lenalidomide + dexamethasone)
  5. Request expedited review - If treatment delay would be harmful
  6. Track status - Follow up if no response within required timeframe
  7. Prepare for renewal - Document ongoing response before current approval expires

Step Therapy Protections in Ohio

Ohio Revised Code § 3901.832 requires insurers to grant step therapy exemptions when specific criteria are met. This is particularly important for multiple myeloma because many patients have already tried multiple treatments.

Automatic Exemption Criteria

Your step therapy exemption must be granted if any of these apply:

  • Contraindication: Required drug is contraindicated per FDA prescribing information
  • Prior failure: You tried the required drug under current or prior plan and discontinued due to lack of efficacy, diminished effect, or adverse event
  • Stability: You're stable on your current provider-selected drug (plan may require trying generic alternative first)

Documentation That Strengthens Your Request

When requesting a step therapy override for Darzalex:

  • Previous treatment records showing trials of lenalidomide, bortezomib, or other required agents
  • Specific adverse events (neuropathy, infections, blood count changes)
  • Disease progression on required therapies
  • Contraindications based on comorbidities or prior reactions
From our advocates: We've seen step therapy overrides approved when providers clearly document not just that prior treatments "failed," but specifically how they failed—progression at 3 months, grade 3 neuropathy requiring dose reduction, or recurrent infections. The more specific the better.

Timeline for Step Therapy Decisions

  • Urgent cases: 48 hours
  • Non-urgent: 10 calendar days
  • Appeals: Provider vs. clinical peer review, same timelines
  • Coverage: Immediate upon approval

Continuity of Care During Plan Changes

Ohio protects ongoing cancer treatment when you switch plans or lose provider access. This is crucial for Darzalex patients who are mid-treatment cycle.

Medicaid Managed Care Protections

If you have Ohio Medicaid (including MyCare Ohio for dual-eligible members):

  • Chemotherapy/radiation: Covered until planned course completion
  • Transplant-related care: Covered until authorized services received
  • No arbitrary end date for ongoing cancer treatment
  • Provider changes limited to member request, provider discontinuation, or health changes

Commercial Plan Protections

Under Ohio Revised Code § 3923.38:

  • 12-month continuation of coverage after employment termination
  • 31-day election period to choose continuation
  • Covers hospital, surgical, and medical benefits (including specialty drugs)

How to Request Continuity of Care

  1. Submit forms promptly - Use plan-specific transition of care forms
  2. Include treatment plan - Document ongoing chemotherapy cycles or planned duration
  3. Provide prior authorization - Show existing approvals from previous plan
  4. Contact member services - Request in-home assessment for complex cases (Medicaid)

External Review and Complaints Process

When Blue Cross Blue Shield denies your Darzalex request and internal appeals fail, Ohio's external review process gives you access to independent medical experts.

When External Review Applies

You can request external review for denials involving:

  • Medical necessity of Darzalex for your specific case
  • Experimental/investigational determinations
  • Clinical appropriateness of your prescribed regimen

Timeline and Process

Standard External Review:

  • 180-day deadline from final internal denial
  • 30-day decision by Independent Review Organization (IRO)
  • 10 business days to submit additional documentation

Expedited External Review:

  • Available when delay would seriously jeopardize health
  • 72-hour decision requirement
  • Can be requested orally or in writing

How to File External Review

  1. Complete internal appeals first (unless urgent or procedural violations)
  2. Request through your health plan - Not directly to Ohio Department of Insurance
  3. Include supporting documents:
    • Final adverse benefit determination letter
    • Medical records and physician letters
    • Treatment history and prior failures
    • Guidelines supporting Darzalex use

The IRO decision is binding - if they overturn the denial, Anthem must cover your treatment.

Practical Scripts for Calls and Appeals

Patient Phone Script for Member Services

"Hi, I'm calling about prior authorization for Darzalex for multiple myeloma. My member ID is [number]. I need to understand the current PA requirements under clinical criteria CC-0127 that was updated in December 2024. Can you tell me the specific form my doctor needs to use and whether there are any step therapy requirements I should know about?"

Clinic Staff Script for Peer-to-Peer Review

"I'm requesting a peer-to-peer review for [patient name] regarding the Darzalex denial. This patient has relapsed multiple myeloma with prior progression on [specific agents]. The prescribed regimen of Darzalex plus lenalidomide and dexamethasone is FDA-approved for this indication and supported by NCCN guidelines. When can we schedule the clinical review?"

Appeal Letter Key Paragraph

"This denial contradicts Ohio Revised Code § 3901.832 regarding step therapy exemptions. The patient previously tried [required drug] under [prior plan/dates] and experienced [specific adverse event/progression]. Darzalex is medically necessary as evidenced by [FDA approval/NCCN guidelines] and the patient's documented treatment history shows contraindication to alternative therapies."

ERISA Plans and Federal vs. State Rules

Important limitation: If you have insurance through a large employer, your plan may be self-funded and governed by federal ERISA law rather than Ohio state protections.

How to Tell the Difference

State-regulated plans (Ohio protections apply):

  • Individual marketplace plans
  • Small group employer plans
  • Some fully insured large group plans

ERISA plans (federal rules):

  • Most large employer plans
  • Self-funded employer plans
  • Summary Plan Description mentions ERISA

ERISA Appeal Process

Even ERISA plans typically follow similar procedures:

  • Internal appeals with clinical review
  • External review (often voluntary or required by federal rules)
  • Similar timelines to Ohio requirements

Key difference: ERISA plans aren't bound by Ohio's step therapy override law, though many follow similar policies voluntarily.

Quick Reference: Contacts and Resources

Ohio Department of Insurance

Blue Cross Blue Shield Ohio (Anthem)

  • Provider Portal: Availity or Anthem provider portal
  • Member Services: Number on your insurance card
  • PA Forms: Current CC-0127 criteria through provider portal

Consumer Assistance

  • UHCAN Ohio: Universal Health Care Action Network for advocacy support
  • OSHIIP: Ohio Senior Health Insurance Information Program (Medicare issues)
  • Legal Aid: For complex appeals or regulatory complaints

Manufacturer Support

  • Janssen CarePath: Patient assistance programs for Darzalex
  • Foundation grants: Leukemia & Lymphoma Society, HealthWell Foundation
  • Copay cards: Available for commercially insured patients

When to Get Help from Counterforce Health

Navigating Blue Cross Blue Shield's prior authorization process for Darzalex can be complex, especially when appeals are needed. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific denial basis and craft point-by-point rebuttals.

For Darzalex appeals, the platform pulls relevant citations from FDA labeling, peer-reviewed studies, and specialty guidelines, weaving them into appeals with required clinical facts like diagnosis codes, prior treatment failures, and dosing rationale. This is particularly valuable for buy-and-bill therapies like Darzalex, where payers expect specific operational details including NDC codes, site of care, and administration plans.

Frequently Asked Questions

How long does Blue Cross Blue Shield PA take in Ohio? Standard requests: up to 10 calendar days. Urgent requests: 48 hours. If Anthem doesn't respond within these timeframes, your request is automatically approved under Ohio law.

What if Darzalex is non-formulary on my plan? You can request a formulary exception with documentation of medical necessity. Include prior treatment failures and why formulary alternatives aren't appropriate for your case.

Can I request an expedited appeal? Yes, if treatment delay would seriously jeopardize your health or cause severe pain. Expedited appeals must be decided within 48 hours for internal review, 72 hours for external review.

Does step therapy apply if I failed treatments outside Ohio? Yes, Ohio's step therapy override law recognizes prior failures under any plan. Document the specific drugs tried, dates, and reasons for discontinuation.

What happens if my employer plan is self-funded? ERISA plans aren't bound by Ohio state laws but typically follow similar procedures. Check your Summary Plan Description for specific appeal rights and timelines.

How much does Darzalex cost without insurance? Cash prices for a single subcutaneous dose typically run several thousand dollars. IV infusions can cost $10,000+ per treatment. Patient assistance programs and copay cards can significantly reduce out-of-pocket costs.

Sources & Further Reading

Disclaimer: This information is for educational purposes and should not replace professional medical or legal advice. Insurance policies and state regulations can change. Always verify current requirements with your specific plan and consult with your healthcare provider about the most appropriate treatment for your condition. For personalized assistance with appeals, consider contacting Counterforce Health or the Ohio Department of Insurance consumer hotline.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.