By Counterforce Health Team in Enbrel (etanercept) —

How to Get Enbrel (etanercept) Covered by Blue Cross Blue Shield in New York: Complete Requirements Guide

Answer Box: Getting Enbrel Covered by Blue Cross Blue Shield in New York

Blue Cross Blue Shield plans in New York require prior authorization for Enbrel (etanercept) with step therapy requirements favoring biosimilars first. Your fastest path to approval: 1) Have your rheumatologist or dermatologist document failed trials of preferred DMARDs and biosimilars, 2) Submit complete TB and hepatitis B screening results within 12 months, and 3) Use an in-network specialty pharmacy. If denied, New York's external appeal process through the Department of Financial Services gives you binding independent review within 30 days.

Start today: Call your BCBS member services to confirm your plan's current formulary status and download the prior authorization form from your provider portal.

Table of Contents

Who Should Use This Guide

This guide is for New York residents with Blue Cross Blue Shield coverage who need Enbrel (etanercept) for rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, plaque psoriasis, or juvenile idiopathic arthritis. You'll find this most helpful if:

  • Your doctor has recommended Enbrel but you haven't started the approval process
  • You've received a denial and need to understand your appeal options
  • You're switching from another biologic and need to navigate step therapy requirements
  • Your clinic staff needs a comprehensive checklist for prior authorization submissions

Expected outcome: With proper documentation, most medically appropriate Enbrel requests get approved, though you may need to try preferred alternatives first. If initially denied, New York's robust appeal system gives you strong consumer protections.

Member & Plan Basics

Coverage Requirements

Your Blue Cross Blue Shield plan must be active with prescription drug benefits. Enbrel requires prior authorization across all BCBS plans in New York, regardless of whether you have commercial, Medicaid, or Medicare coverage.

Plan Type Considerations

  • Commercial plans: Standard prior authorization through your BCBS plan
  • Medicaid managed care: Prior authorization plus potential state Fair Hearing appeals
  • Medicare Part D: Different appeal timelines; external review through Medicare, not New York DFS

Cost-Sharing Structure

Enbrel typically falls on specialty drug tiers with higher copays or coinsurance. Your annual deductible may apply before coverage begins. Contact member services at the number on your insurance card to confirm your specific cost-sharing.

Clinical Criteria for Approval

FDA-Approved Indications

Enbrel must be prescribed for an FDA-approved indication:

  • Rheumatoid arthritis (moderate to severe)
  • Psoriatic arthritis
  • Ankylosing spondylitis
  • Plaque psoriasis (moderate to severe)
  • Polyarticular juvenile idiopathic arthritis

Step Therapy Requirements

Most BCBS plans require you to try and fail preferred medications first:

For Rheumatoid Arthritis:

  • At least 3 months of a conventional DMARD (typically methotrexate)
  • Documentation of inadequate response, intolerance, or contraindication
  • Preference for etanercept biosimilars over brand-name Enbrel

For Plaque Psoriasis:

  • Trial of topical therapies (corticosteroids, vitamin D analogs)
  • At least 3 months of methotrexate (unless contraindicated)
  • Disease severity: ≥3% body surface area OR involvement of sensitive areas

Prescriber Requirements

Initial prescriptions must come from or be approved by:

  • Rheumatologist (for arthritis conditions)
  • Dermatologist (for psoriasis)
  • Relevant specialist for other indications

Safety Screening

Required before approval:

  • Tuberculosis screening (negative TB test within 12 months)
  • Hepatitis B screening (surface antigen and core antibody)
  • Complete blood count and liver function tests
  • Documentation of no active serious infections

Coding Requirements

ICD-10 Diagnosis Codes

Use specific codes matching your condition:

Condition Primary ICD-10 Codes
Rheumatoid Arthritis M05.XXX (seropositive), M06.0XX (seronegative)
Psoriatic Arthritis L40.50-L40.59
Ankylosing Spondylitis M45.X
Plaque Psoriasis L40.0-L40.9
Juvenile Idiopathic Arthritis M08.XXX

HCPCS/J-Codes

  • J1438: Injection, etanercept, 25 mg (standard billing code)
  • Ensure units match prescribed dosing (typically 2 units for 50 mg weekly)

Documentation Packet

Provider Note Requirements

Your specialist's documentation must include:

  • Confirmed diagnosis with supporting clinical findings
  • Complete medication history with dates, dosages, and outcomes
  • Current disease activity assessment
  • Treatment goals and expected outcomes
  • Safety screening results

Medical Necessity Letter Components

A comprehensive letter should address:

  1. Patient demographics and diagnosis
  2. Prior therapy documentation:
    • Specific medications tried
    • Duration of each trial
    • Reason for discontinuation (ineffective, intolerance, contraindication)
  3. Clinical rationale for Enbrel:
    • Why biosimilars aren't appropriate (if applicable)
    • Expected clinical benefits
    • Monitoring plan
  4. Safety considerations:
    • TB screening: "Patient underwent tuberculosis screening via [PPD/QuantiFERON] on [date] with negative results"
    • Hepatitis B screening: "Hepatitis B surface antigen and core antibody tested on [date], both negative"

Required Attachments

  • Recent clinic notes (within 90 days)
  • Laboratory results (TB screening, hepatitis B, CBC, liver function)
  • Previous medication trial documentation
  • Imaging studies (if relevant to diagnosis)

Submission Process

Correct Forms and Portals

  • Download the current prior authorization form from your BCBS provider portal
  • Forms change annually; verify you have the 2024 version
  • Complete all required fields—incomplete submissions cause automatic delays

Submission Methods

Provider portal: Fastest processing, immediate confirmation Fax: Backup option; request delivery confirmation Mail: Slowest option; use certified mail for tracking

Common Rejection Triggers

  • Missing prescriber specialty information
  • Incomplete medication history
  • Outdated screening results
  • Wrong ICD-10 codes
  • Missing patient signature (where required)

Specialty Pharmacy Requirements

Enbrel must be dispensed through an in-network specialty pharmacy. Using out-of-network pharmacies will result in denial of coverage.

BCBS-Preferred Specialty Pharmacies in New York

  • CVS Specialty
  • BioPlus Specialty Pharmacy
  • Mount Sinai Specialty Pharmacy
  • NewYork-Presbyterian Specialty Pharmacy Program
  • NYU Langone Specialty Pharmacy at Industry City

Transfer Process

  1. Your prescriber sends the prescription directly to the specialty pharmacy
  2. The pharmacy contacts you to coordinate delivery
  3. Someone must be available to receive refrigerated medication
  4. Confirm your copay assistance card is on file before shipment

After Submission: What to Expect

Processing Timeline

  • Standard review: 72 hours for urgent requests, 15 days for routine
  • Incomplete submissions: Additional 15 days after missing information provided
  • Appeals: 30 days for internal review, 30 days for external review

Status Monitoring

  • Record your prior authorization reference number
  • Check status through the provider portal weekly
  • Follow up if you don't receive a decision within expected timeframes

Approval Specifications

  • Initial approvals typically last 12 months
  • Quantity limits: usually 50 mg weekly maximum
  • Renewal requires documentation of clinical benefit

Common Denial Reasons & How to Fix Them

Denial Reason Solution Documentation Needed
Step therapy not completed Document failed trials of preferred agents Medication history with dates and outcomes
Inadequate diagnosis documentation Submit specialist evaluation Rheumatologist/dermatologist consultation
Missing safety screening Complete required tests TB and hepatitis B results within 12 months
Non-preferred agent Request medical exception Letter explaining why biosimilars inappropriate
Quantity limit exceeded Justify dosing Clinical rationale for higher dose

Appeals Process in New York

Internal Appeals (First Step)

  • Timeline: Must file within timeframe specified in your denial letter
  • Process: Submit appeal through BCBS member portal or by mail
  • Documentation: Include all supporting clinical information
  • Decision: BCBS has 30 days for standard appeals, 72 hours for expedited

External Appeals (New York DFS)

If your internal appeal is denied, you can request an independent external review:

  • Eligibility: Fully-insured commercial plans and Medicaid managed care
  • Timeline: 4 months after final internal denial to file
  • Cost: $25 fee (waived for Medicaid or financial hardship)
  • Process: Submit NY State External Appeal Application to DFS
  • Decision: Binding on insurer; 30 days for standard, 72 hours for expedited

Filing Your External Appeal

  1. Download the NY State External Appeal Application
  2. Attach all supporting documentation
  3. Submit by fax: (800) 332-2729 or mail to: DFS, PO Box 7209, Albany NY 12224
  4. For help: Call DFS at (800) 400-8882 or Community Health Advocates at (888) 614-5400

Costs & Patient Support Options

Manufacturer Support

  • Enbrel Co-Pay Program: May reduce out-of-pocket costs for eligible patients
  • Patient assistance programs: Available for uninsured or underinsured patients
  • Information: Visit Enbrel.com for current eligibility

Additional Resources

  • State pharmaceutical assistance programs
  • Non-profit foundations offering grants for specialty medications
  • Hospital charity care programs

Quick Reference Checklist

Before Starting:

  • Confirm active BCBS coverage with prescription benefits
  • Identify in-network specialty pharmacy
  • Gather insurance card and policy information

Clinical Documentation:

  • Specialist evaluation (rheumatologist/dermatologist)
  • ICD-10 diagnosis code confirmed
  • Prior medication trials documented with dates and outcomes
  • TB screening completed (negative within 12 months)
  • Hepatitis B screening completed (negative)

Submission Requirements:

  • Current prior authorization form completed
  • Medical necessity letter from specialist
  • All required attachments included
  • Submission method confirmed (portal preferred)

After Submission:

  • Prior authorization reference number recorded
  • Status check schedule established
  • Appeal timeline noted if denied

FAQ

How long does BCBS prior authorization take in New York? Standard reviews take up to 15 days, urgent requests within 72 hours. Processing starts when complete documentation is received.

What if Enbrel is non-formulary on my plan? You can request a formulary exception with documentation of medical necessity and failed trials of formulary alternatives.

Can I request an expedited appeal? Yes, if your health would be seriously jeopardized by delay. Both internal and external appeals offer expedited timelines in New York.

Does step therapy apply if I failed medications outside New York? Yes, prior therapy trials from other states count toward step therapy requirements if properly documented.

What happens if my external appeal is approved? BCBS must cover the treatment and refund your $25 appeal fee. The decision is binding and cannot be overturned by the insurer.

How do I prove medical necessity for brand Enbrel over biosimilars? Document specific clinical reasons such as previous biosimilar failure, allergies to biosimilar components, or other contraindications.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned to each payer's specific requirements, pulling the right medical evidence and clinical documentation to strengthen your case.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies change frequently; always verify current requirements with your specific BCBS plan. For personalized assistance with insurance appeals and prior authorizations, consider consulting with Counterforce Health or other qualified advocacy services.

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