By Counterforce Health Team in Emflaza (deflazacort) —

How to Get Emflaza (Deflazacort) Covered by Blue Cross Blue Shield in New Jersey: Complete 2025 Guide

Answer Box: Getting Emflaza Covered in New Jersey

To get Emflaza (deflazacort) covered by Blue Cross Blue Shield in New Jersey, you need: (1) confirmed Duchenne muscular dystrophy diagnosis with genetic testing, (2) documentation of prednisone/prednisolone trial failure or intolerance, and (3) prior authorization from a DMD specialist. First step today: Have your doctor gather your genetic test results and steroid trial records, then submit the Horizon BCBSNJ prior authorization form. If denied, New Jersey's external appeal process through Maximus Federal Services has a 20-40% overturn rate for specialty drugs.

Table of Contents

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all BCBS plans Member portal or provider manual Horizon BCBSNJ PA List
Formulary Tier Specialty/Non-Preferred Brand (Tier 3) Current year formulary 2025 Formulary
Step Therapy Prednisone/prednisolone trial required PA criteria document Deflazacort Criteria
Age Requirement 2 years or older FDA label and PA criteria UHC PA Notice
Specialty Pharmacy Must use BCBS network specialty pharmacy Specialty drug list Horizon Specialty Pharmacy
Diagnosis Code Duchenne muscular dystrophy (G71.0) Medical records Clinical documentation

Step-by-Step: Fastest Path to Approval

1. Confirm Your Diagnosis Documentation (Patient/Family)

  • Gather genetic testing results showing DMD gene mutation
  • Collect elevated creatine kinase (CK) lab results
  • Timeline: Same day
  • Source: CDC DMD Clinical Overview

2. Document Step Therapy History (Prescriber)

  • Review medical records for prednisone/prednisolone trials
  • Document specific adverse effects or treatment failure
  • Timeline: 1-2 business days
  • Form: Include in PA request narrative

3. Complete Prior Authorization (Prescriber)

4. Route to Specialty Pharmacy (Prescriber/Patient)

5. Monitor PA Decision (Patient)

  • Check member portal for determination
  • Timeline: 72 hours for standard, 24 hours for urgent
  • Next step: If denied, prepare appeal immediately

Medical Necessity Requirements

Blue Cross Blue Shield in New Jersey requires all of the following criteria for Emflaza coverage:

Confirmed DMD Diagnosis

  • Genetic testing: Laboratory confirmation of DMD gene mutation
  • Clinical presentation: Progressive muscle weakness, elevated CK levels
  • Age requirement: Patient must be 2 years or older
  • Source: Horizon BCBSNJ Deflazacort Criteria

Specialist Management

  • Prescription must be written by or in consultation with a physician specializing in DMD treatment
  • Neurologist, pediatric neurologist, or neuromuscular specialist preferred
  • Documentation tip: Include specialist consultation notes in PA submission

Clinical Monitoring Plan

  • Regular assessment of motor function and disease progression
  • Monitoring for corticosteroid side effects
  • Growth and development tracking (pediatric patients)
Clinician Corner: Medical Necessity Letter Checklist

Your PA letter should include:DMD diagnosis with genetic confirmationCurrent functional status and disease progressionPrior corticosteroid trials and outcomesSpecific adverse effects from prednisone/prednisoloneTreatment goals and monitoring planCitations: FDA Emflaza label and DMD Care Guidelines

Step Therapy & Exceptions

Standard Step Therapy Requirement

Blue Cross Blue Shield typically requires documented trial and failure of:

  • Prednisone at appropriate doses for DMD
  • Prednisolone as alternative first-line therapy
  • Duration: Adequate trial period per clinical guidelines
  • Source: BCBS Step Therapy Guidelines

Medical Exceptions

Step therapy may be waived if:

  • Contraindications: Patient cannot safely use prednisone/prednisolone
  • Prior adverse effects: Documented clinically significant side effects
  • Treatment failure: Inadequate response to preferred agents
  • Clinical urgency: Delay would compromise patient safety

Documenting Treatment Failure

Include specific details:

  • Medication names, doses, and duration tried
  • Objective measures of treatment failure
  • Adverse effects experienced (weight gain, behavioral changes, growth suppression)
  • Clinical rationale for deflazacort over alternatives

Specialty Pharmacy Requirements

Emflaza must be dispensed through a BCBS-approved specialty pharmacy in New Jersey:

Network Specialty Pharmacies

  • Accredo Specialty Pharmacy
  • CVS Specialty
  • OptumRx Specialty
  • Verify current network: Contact member services for updated list

Prescription Routing

  • Prescriptions sent to regular retail pharmacies will be rejected
  • Specialty pharmacies handle PA coordination and insurance verification
  • Home delivery typically included at no extra cost

Supply Limits

  • Initial fills may be limited to 30-day supply
  • Ongoing refills up to 90-day supply with PA approval
  • Early refill restrictions may apply

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Insufficient DMD diagnosis Submit genetic testing results Lab report showing DMD gene mutation
Step therapy not met Document prednisone/prednisolone failure Medical records with trial details and outcomes
Not medically necessary Provide clinical justification Specialist letter citing treatment guidelines
Age restriction Confirm patient ≥2 years old Birth certificate or medical records
Non-formulary drug Request formulary exception Medical necessity letter with alternatives comparison

Appeal-Winning Documentation

Based on successful New Jersey appeals, include:

  • Complete medical history and current clinical status
  • Peer-reviewed studies supporting deflazacort use in DMD
  • Comparison of deflazacort vs. prednisone side effect profiles
  • Treatment goals and expected outcomes

Appeals Process in New Jersey

If your initial PA is denied, New Jersey offers a robust appeals system:

Internal Appeals (BCBS)

  • Timeline: Submit within 60 days of denial notice
  • Levels: Two levels of internal review required
  • Method: BCBS member portal or written appeal
  • Duration: 30 days for standard, 72 hours for urgent

External Review (IHCAP)

New Jersey's Independent Health Care Appeals Program provides binding external review:

  • Administered by: Maximus Federal Services
  • Eligibility: Must complete internal appeals first
  • Timeline: 4 months from final denial to file
  • Cost: $25 fee for HMO members
  • Success rate: 20-40% overturn rate for specialty drugs
  • Source: NJ DOBI IHCAP Information

Expedited Appeals

Request expedited review if:

  • Standard timeline would seriously jeopardize health
  • Patient currently on deflazacort therapy
  • Interruption would cause disease progression
From Our Advocates

A composite example: One family successfully appealed an Emflaza denial by submitting detailed records showing their child's significant weight gain and behavioral issues on prednisone, along with a specialist letter explaining why deflazacort's improved side effect profile was medically necessary for long-term DMD management. The external review overturned the denial within 30 days.

Cost and Financial Assistance

Insurance Coverage

  • Copay/Coinsurance: Varies by plan; specialty tier typically 25-40% coinsurance
  • Deductible: May apply to specialty medications
  • Out-of-pocket maximum: Annual limit provides cost protection

Manufacturer Support

  • PTC Therapeutics Patient Support: Copay assistance and insurance navigation
  • Eligibility: Commercial insurance patients meeting income requirements
  • Contact: Verify current programs through prescriber or Emflaza.com

Foundation Assistance

  • Muscular Dystrophy Association (MDA) equipment and support services
  • Patient advocacy organizations may provide emergency assistance
  • State pharmaceutical assistance programs for eligible New Jersey residents

FAQ

How long does BCBS prior authorization take in New Jersey? Standard PA decisions are made within 72 hours of complete submission. Urgent requests are processed within 24 hours. Source: Horizon BCBSNJ Provider Manual

What if Emflaza is not on my formulary? You can request a formulary exception through the PA process. Include medical necessity documentation and comparison with formulary alternatives.

Can I request an expedited appeal? Yes, if delay would seriously jeopardize your health or if you're currently on deflazacort therapy. Both internal and external appeals can be expedited.

Does step therapy apply if I failed prednisone outside New Jersey? Yes, documented treatment failures from other states are typically accepted if properly documented in medical records.

What happens if my external appeal is denied? IHCAP decisions are binding in New Jersey. Further options may include legal review or complaint to the NJ Department of Banking and Insurance.

How much does Emflaza cost without insurance? List prices vary by strength, with 6mg tablets approximately $9-12 each. Monthly costs can exceed $3,000 without coverage. [Source: GoodRx pricing data]

Can my doctor request a peer-to-peer review? Yes, most BCBS plans offer peer-to-peer consultations where your prescriber can discuss the case directly with a plan medical director.

What if I need Emflaza immediately? Request expedited PA and appeal processes. Your doctor can also provide samples or work with the specialty pharmacy for emergency supplies while appeals are pending.

About Counterforce Health

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 appeal letters that address specific denial reasons with the right clinical citations and procedural requirements.

When facing complex prior authorization requirements like those for Emflaza in New Jersey, having the right documentation and appeal strategy can make the difference between coverage and costly out-of-pocket expenses. Counterforce Health's approach has helped countless families navigate these challenging coverage decisions.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and coverage criteria can change. Always verify current requirements with your specific Blue Cross Blue Shield plan and consult with your healthcare provider for medical decisions. For personalized assistance with New Jersey insurance appeals, contact the NJ Department of Banking and Insurance Consumer Hotline at 1-800-446-7467.

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