By Counterforce Health Team in Enbrel (etanercept) —

How to Get Enbrel (Etanercept) Covered by Blue Cross Blue Shield in Ohio: Complete Requirements Guide

Answer Box: Getting Enbrel Covered by Blue Cross Blue Shield in Ohio

Blue Cross Blue Shield in Ohio requires prior authorization for Enbrel (etanercept), typically mandating step therapy with biosimilar alternatives first. To get approval: 1) Complete the PA form with detailed clinical documentation showing failed trials of conventional DMARDs and biosimilars, 2) Include required TB and hepatitis B screening results, and 3) Submit through your prescriber via the Anthem provider portal or designated fax line. If denied, you have 180 days to request external review through the Ohio Department of Insurance.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria for Enbrel Approval
  4. Required Documentation Packet
  5. Submission Process
  6. Specialty Pharmacy Requirements
  7. After Submission: What to Expect
  8. Appeals Process in Ohio
  9. Common Denial Reasons & How to Fix Them
  10. FAQ

Who Should Use This Guide

This guide is for Ohio residents with Blue Cross Blue Shield coverage who need Enbrel (etanercept) for:

  • Rheumatoid arthritis (RA)
  • Psoriatic arthritis (PsA)
  • Ankylosing spondylitis (AS)
  • Moderate to severe plaque psoriasis
  • Polyarticular juvenile idiopathic arthritis

Expected outcome: With proper documentation, most medically appropriate requests are approved within 3-5 business days. If initially denied, appeals have a strong success rate when biosimilar alternatives are contraindicated or have failed.

Member & Plan Basics

Coverage Requirements

  • Active Blue Cross Blue Shield coverage in Ohio (verify through member portal)
  • Prior authorization required for all Enbrel prescriptions
  • Specialist prescriber typically required (rheumatologist, dermatologist)
  • Step therapy compliance - must try biosimilar etanercept products first

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for all Enbrel prescriptions Anthem provider portal
Step Therapy Must try biosimilars first (unless contraindicated) Plan formulary
Specialty Pharmacy Accredo typically preferred Member services
Appeals Timeline 180 days from denial Ohio Department of Insurance
External Review Available after internal appeals ODI External Review System

Clinical Criteria for Enbrel Approval

Required Diagnosis Codes (ICD-10)

  • 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 Arthritis: M08.XXX

Step Therapy Requirements

Before Enbrel approval, you must document:

  1. Trial of conventional DMARDs (typically methotrexate) for at least 3 months
  2. Trial of etanercept biosimilar (unless contraindicated)
  3. Reason for failure or intolerance with specific dates and outcomes

Safety Screening Requirements

  • Tuberculosis screening within 12 months (PPD or IGRA test)
  • Hepatitis B screening (HBsAg and anti-HBc)
  • Complete blood count and liver function tests
  • Chest X-ray if indicated
Note: Active infections, untreated latent TB, or positive hepatitis B are contraindications that will result in denial.

Required Documentation Packet

Medical Necessity Letter Components

Your prescriber's letter must include:

  1. Patient demographics and insurance information
  2. Specific diagnosis with ICD-10 codes
  3. Disease severity and impact on quality of life
  4. Prior therapy history:
    • Drug names, dosages, duration of trial
    • Specific reasons for discontinuation
    • Dates of treatment periods
  5. Clinical rationale for Enbrel specifically
  6. Treatment goals and expected outcomes

Required Attachments

  • Recent clinic notes (within 90 days)
  • Lab results (TB screening, hepatitis B, CBC, liver function)
  • Prior authorization form (complete all sections)
  • Insurance card copy
  • Any prior denial letters
Clinician Corner: The most successful medical necessity letters include specific quotes from FDA labeling or ACR guidelines supporting the use of TNF inhibitors after conventional DMARD failure. Include exact dates of prior therapies and quantifiable measures of disease activity when possible.

Submission Process

Step-by-Step: Fastest Path to Approval

  1. Gather Documentation (Patient/Clinic)
    • Complete safety screening labs
    • Document prior therapy failures
    • Obtain recent clinic notes
  2. Complete PA Form (Prescriber)
    • Use current Anthem Ohio PA form
    • Fill all required fields completely
    • Include prescriber DEA and NPI numbers
  3. Submit Package (Clinic Staff)
    • Submit via Anthem provider portal (preferred)
    • Or fax to designated PA number (verify current number)
    • Keep confirmation receipt
  4. Follow Up (Clinic/Patient)
    • Check status after 3 business days
    • Respond promptly to any requests for additional information

Common Submission Errors to Avoid

  • Incomplete safety screening documentation
  • Missing specific dates of prior therapy trials
  • Using outdated PA forms
  • Insufficient clinical documentation of disease severity

Specialty Pharmacy Requirements

Accredo is typically the preferred specialty pharmacy for Blue Cross Blue Shield Ohio members receiving Enbrel. Other options may include CVS Specialty, but always verify with your specific plan.

Specialty Pharmacy Process

  1. Prescriber sends prescription to designated specialty pharmacy
  2. Pharmacy contacts patient to arrange delivery
  3. Prior authorization must be approved before shipment
  4. Home delivery with temperature-controlled shipping
  5. Patient must be available to receive and immediately refrigerate
Tip: Contact member services at the number on your insurance card to confirm which specialty pharmacy is preferred for your specific plan year.

After Submission: What to Expect

Timeline

  • Initial review: 3-5 business days
  • Peer-to-peer review (if requested): Additional 1-2 days
  • Final determination: Communicated via phone and letter

Status Tracking

  • Check status through provider portal
  • Record confirmation numbers
  • Document all communications with dates and representatives

If Additional Information is Requested

  • Respond within the specified timeframe (usually 10-14 days)
  • Provide exactly what is requested
  • Follow up to confirm receipt

Appeals Process in Ohio

Internal Appeals (Blue Cross Blue Shield)

  • Timeline: Must file within 180 days of denial
  • Process: Submit appeal letter with additional documentation
  • Decision: Typically within 30 days (15 days for urgent cases)

External Review (Ohio Department of Insurance)

  • Eligibility: After exhausting internal appeals
  • Timeline: 180 days from final internal denial
  • Process: Submit through Ohio External Review System
  • Decision: 30 days (72 hours for expedited)
  • Contact: 614-644-0188 or [email protected]
Important: External review decisions are binding on the insurer. If approved, your plan must cover the treatment.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
Step therapy not completed Document biosimilar trial/failure or contraindication
Insufficient clinical documentation Submit detailed clinic notes showing disease severity
Missing safety screening Provide complete TB/hepatitis B lab results
Non-preferred prescriber Have rheumatologist/specialist submit request
Dosing/frequency issues Justify dosing with FDA labeling or guidelines

FAQ

How long does Blue Cross Blue Shield prior authorization take in Ohio? Typically 3-5 business days for standard reviews, with expedited reviews available for urgent cases.

What if Enbrel is not on my formulary? You can request a formulary exception with documentation of medical necessity and failed alternatives.

Can I request an expedited appeal? Yes, if delaying treatment would seriously endanger your health. Your doctor must certify the urgency.

Does step therapy apply if I've tried biosimilars in another state? Yes, but you'll need to provide documentation of the previous trials and outcomes.

What happens if my external review is denied? The decision is final administratively, but you may have other legal remedies available.

How much does Enbrel cost with Blue Cross Blue Shield coverage? Costs vary by plan, but specialty drug copays typically range from $50-$200 per month after deductible.

Can I use manufacturer copay assistance? Yes, Amgen offers the Enbrel Support program for eligible patients with commercial insurance.

What if I need Enbrel while traveling? Coordinate with your specialty pharmacy for temporary supply arrangements and ensure proper storage.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals for patients needing prescription medications like Enbrel. Our platform analyzes denial letters and creates targeted, evidence-backed appeals that address the specific criteria used by payers like Blue Cross Blue Shield. By combining clinical expertise with payer-specific knowledge, we help patients, clinicians, and specialty pharmacies navigate the complex prior authorization process more effectively.

For more information about our services, visit www.counterforcehealth.org.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies may change, and individual circumstances vary. Always consult with your healthcare provider and insurance company for the most current information specific to your situation. For assistance with insurance appeals in Ohio, contact the Ohio Department of Insurance Consumer Services at 1-800-686-1526.

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