By Counterforce Health Team in Dupixent (dupilumab) —

How to Get Dupixent (dupilumab) Covered by Blue Cross Blue Shield in Ohio: Prior Authorization, Appeals, and Step Therapy Override Guide

Answer Box: Getting Dupixent Covered in Ohio

Blue Cross Blue Shield (primarily Anthem) in Ohio requires prior authorization for Dupixent (dupilumab) with step therapy requirements varying by indication. Ohio's step therapy override law (ORC §3901.832) requires approval within 72 hours if you've failed preferred treatments or have contraindications. The fastest path: 1) Check your formulary tier at anthem.com, 2) Submit PA with documented step therapy failures, 3) If denied, file internal appeal citing Ohio's override protections. Start by calling the number on your member ID card.

Table of Contents

Why Ohio State Rules Matter

Ohio's insurance laws provide crucial protections that work alongside your Blue Cross Blue Shield plan policies. Ohio Revised Code §3901.832 governs step therapy overrides for all health plans in the state, including Anthem Blue Cross Blue Shield (the primary BCBS affiliate in Ohio).

These state protections apply to fully insured commercial plans, individual marketplace plans, and some employer plans. However, large employer self-funded plans follow federal ERISA rules instead—though many voluntarily adopt similar processes.

Key Ohio advantages:

  • Mandatory 72-hour decision timeline for step therapy overrides
  • Prior therapy failures from any state count toward requirements
  • Clear medical exception criteria that insurers must follow
  • External review through Ohio Department of Insurance with 35-42% success rates

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Dupixent indications Anthem formulary search Anthem Ohio Formulary
Step Therapy Must try/fail preferred treatments first Plan-specific PA criteria Ohio Step Therapy Law
Quantity Limits Max doses per indication (e.g., 300mg/2 weeks) Plan formulary details Plan documents
Age Restrictions ≥6 months for atopic dermatitis FDA labeling requirements FDA Dupixent Label
ICD-10 Codes L20.x (atopic dermatitis), J45.x (asthma) Medical necessity documentation Provider documentation
Appeals Deadline 60 days for internal, 180 days for external Ohio insurance law Ohio DOI Appeals Process

Turnaround Standards and Timelines

Ohio law sets specific deadlines that Blue Cross Blue Shield must follow:

Prior Authorization Decisions:

  • Standard: 15 business days
  • Expedited (urgent): 72 hours
  • Step therapy override: 72 hours (non-urgent) or 24 hours (expedited)

Appeal Timelines:

  • Internal Level 1: 15 days (72 hours if urgent)
  • Internal Level 2: 15 days (72 hours if urgent)
  • External review: 30 days (72 hours if expedited)
Tip: Document when you submit requests. If deadlines pass, this strengthens your appeal case.

Step Therapy Protections in Ohio

Ohio's step therapy override law requires insurers to approve exceptions when:

  1. Prior failure: You tried and failed a preferred drug therapy
  2. Contraindication: Preferred drug is medically inappropriate (allergy, interaction)
  3. Previous stability: You were stable on the requested drug, and switching would be detrimental

Documentation requirements:

  • Medical necessity letter from prescriber
  • Chart notes showing trial duration, dose, and failure
  • Lab results or imaging (IgE levels for atopic dermatitis, FEV1 for asthma)

Common step therapy requirements by indication:

Indication Required Prior Therapies
Atopic Dermatitis Topical corticosteroids, calcineurin inhibitors (tacrolimus), or systemic therapies
Asthma High-dose inhaled corticosteroids + LABA; leukotriene modifiers
COPD Triple therapy (LAMA/LABA/ICS) for 3 months
Chronic Rhinosinusitis Nasal steroids, surgery consideration

Fastest Path to Approval

Step 1: Verify Coverage and Requirements

Call the member services number on your insurance card to confirm:

  • Formulary tier for Dupixent
  • Specific PA requirements for your indication
  • Required prior therapies

Step 2: Gather Documentation

For your prescriber to include:

  • Complete medical history and diagnosis (with ICD-10 codes)
  • Documentation of prior therapy trials and failures
  • Clinical rationale citing FDA labeling or specialty guidelines
  • Planned dosing and monitoring schedule

Step 3: Submit Prior Authorization

Submit through:

  • Anthem provider portal (for providers)
  • Fax: Check current fax number with member services
  • Phone: 1-800-454-3730 (Ohio provider services)

Step 4: Follow Up Strategically

  • Standard PA: Follow up after 10 business days
  • Urgent cases: Request expedited review upfront
  • Missing information: Respond within 24-48 hours

Step 5: Prepare for Potential Denial

Gather additional evidence:

  • Peer-reviewed studies supporting Dupixent for your condition
  • Specialist consultation notes
  • Documentation of contraindications to preferred therapies

Common Denial Reasons & Solutions

Denial Reason How to Overturn
"Lack of medical necessity" Submit detailed clinical notes, specialist consultation, severity documentation
"Step therapy not completed" Document prior therapy failures with dates, doses, and reasons for discontinuation
"Diagnosis not supported" Include lab results (IgE, eosinophil count), imaging, specialist evaluation
"Quantity exceeds limits" Provide weight-based dosing calculation, FDA labeling support
"Not FDA-approved indication" Cite peer-reviewed studies, specialty guidelines for off-label use

Appeals Playbook for Ohio

Internal Appeals (Required First Step)

Level 1 Appeal:

  • File within 60 days of denial
  • Submit via member portal or mail to address on denial letter
  • Include: Original denial letter, prescriber letter, medical records, new evidence
  • Decision timeline: 15 days (72 hours if urgent)

Level 2 Appeal:

  • File within 60 days of Level 1 denial
  • Often involves peer-to-peer review with medical director
  • Same documentation requirements plus any new evidence

External Review (Ohio Department of Insurance)

File within 180 days of final internal denial through your health plan. The plan forwards your request to Ohio DOI, which assigns an Independent Review Organization (IRO).

Success rates: 35-42% of external reviews overturn denials, with specialty drug cases often having higher success rates when properly documented.

Contact: Ohio Department of Insurance at 1-800-686-1526

Continuity of Care Transitions

If your provider leaves the Anthem network while you're on Dupixent, you may qualify for continuity of care benefits:

  • Automatic coverage: If you've seen the same provider 3+ times in 6 months for qualifying conditions
  • Duration: Up to 90 days of in-network benefits
  • Qualifying conditions: Chronic conditions, cancer, pregnancy, terminal illness

Submit a Continuity of Care request within 90 days of receiving notification.

External Review and Consumer Assistance

Ohio provides strong consumer protections through its external review process:

When to use external review:

  • After exhausting internal appeals
  • For denials involving medical judgment
  • When you believe the denial violates Ohio law

Ohio Department of Insurance resources:

Additional consumer assistance:

  • UHCAN Ohio (Universal Health Care Action Network)
  • Legal aid societies for complex cases
  • OSHIIP for Medicare-related issues

Costs and Patient Support

Dupixent pricing: List price approximately $3,993 per carton (2 injections) as of January 2025.

Financial assistance options:

  • Dupixent MyWay: Copay assistance for eligible commercial insurance patients
  • Sanofi Patient Connection: Income-based assistance program
  • State pharmaceutical assistance programs
  • Hospital charity care programs
Note: Copay assistance typically doesn't apply to government insurance (Medicare, Medicaid).

FAQ

How long does Anthem's prior authorization process take in Ohio? Standard PA decisions are made within 15 business days, with expedited reviews completed in 72 hours for urgent cases.

What if Dupixent isn't on my formulary? You can request a formulary exception by demonstrating medical necessity and providing evidence that preferred alternatives are inappropriate.

Can I request an expedited appeal in Ohio? Yes, if delaying treatment would seriously jeopardize your health. Both internal and external appeals can be expedited with 72-hour decision timelines.

Does Ohio's step therapy law apply to all insurance plans? The law applies to fully insured plans regulated by Ohio. Self-funded employer plans follow federal ERISA rules but may voluntarily adopt similar protections.

What happens if I move to Ohio while already on Dupixent? Prior therapy failures from other states count toward Ohio step therapy requirements. Document your treatment history for continuity.

How successful are appeals for specialty biologics like Dupixent? National data shows 80-83% of prior authorization appeals succeed, with Ohio external reviews overturning 35-42% of denials.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that address the specific reasons for denial. By identifying whether denials stem from PA criteria, step therapy requirements, or "not medically necessary" determinations, Counterforce Health streamlines the appeals process with the right clinical evidence and procedural requirements for each payer.

For complex cases involving specialty biologics like Dupixent, having the right documentation and understanding payer-specific workflows can make the difference between approval and denial. Counterforce Health's approach helps ensure that appeals meet both clinical standards and administrative requirements, reducing the back-and-forth that often delays patient access to needed treatments.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance company for specific coverage decisions. For assistance with appeals or coverage issues, contact the Ohio Department of Insurance at 1-800-686-1526.

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