By Counterforce Health Team in Enbrel (etanercept) —

How to Get Enbrel (Etanercept) Covered by Blue Cross Blue Shield in Washington: Complete PA Guide & Appeal Process

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

Blue Cross Blue Shield of Washington (Premera Blue Cross) requires prior authorization for Enbrel (etanercept) and typically mandates step therapy with biosimilar alternatives first. Here's your fastest path to approval:

  1. Complete PA form: Have your rheumatologist submit Premera's Pre-service Authorization form via Availity portal or fax to 800-843-1114
  2. Document medical necessity: Include diagnosis codes, failed DMARD trials, TB/hepatitis screening results, and disease severity scores
  3. Use specialty pharmacy: Prescriptions must go through Accredo or AllianceRx Walgreens Prime for coverage

Start today: Contact your prescribing doctor to initiate the prior authorization process. Standard decisions take 5-10 business days, with expedited reviews available for urgent cases.

Table of Contents

  1. Plan Types & Coverage Differences
  2. Formulary Status & Tier Placement
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Network
  5. Step-by-Step Approval Process
  6. Common Denial Reasons & Solutions
  7. Appeals Process in Washington
  8. Cost-Saving Programs
  9. FAQ

Plan Types & Coverage Differences

Blue Cross Blue Shield of Washington (operating as Premera Blue Cross) offers HMO, PPO, and EPO plans with different requirements for accessing Enbrel:

Plan Type PCP Required Referral for Rheumatologist Network Restrictions Premium Cost
HMO Yes Usually required In-network only Lowest
PPO No Not required Out-of-network covered at higher cost Highest
EPO No Not required In-network only Mid-range

Key implications for Enbrel coverage:

  • All plan types cover Enbrel when medically necessary and properly authorized
  • HMO members typically need a referral from their primary care physician to see a rheumatologist
  • Prior authorization requirements apply regardless of plan type
  • Specialty pharmacy requirements are consistent across all plans

Formulary Status & Tier Placement

Enbrel appears on Premera's formulary as a preferred specialty medication, typically placed in Tier 2 or 3 with the following characteristics:

Coverage Requirements:

  • Prior authorization mandatory
  • Quantity limits (typically 4 syringes per 28 days)
  • Step therapy requirements
  • Specialty pharmacy dispensing only

Alternative Agents: Premera may require trials of biosimilar alternatives like Erelzi or Eticovo before approving brand-name Enbrel, unless medically contraindicated.

Note: Formulary placement can change annually. Verify current status through Premera's drug lookup tool or your member portal.

Prior Authorization Requirements

Required Documentation

Your rheumatologist must submit comprehensive clinical documentation including:

Diagnosis Information:

  • Confirmed diagnosis with appropriate ICD-10 codes (M05-M06 for RA, L40 for psoriasis)
  • Disease severity scores (DAS28 for RA, BASDAI for ankylosing spondylitis)
  • Objective evidence of active disease

Treatment History:

  • Documentation of failed conventional DMARD trials (typically methotrexate, sulfasalazine, or leflunomide)
  • Duration of previous treatments (usually 3+ months required)
  • Reasons for discontinuation (lack of efficacy, intolerance, contraindications)

Safety Screening:

  • Tuberculosis screening (chest X-ray, tuberculin skin test, or interferon-gamma release assay)
  • Hepatitis B surface antigen and core antibody testing
  • Complete blood count and liver function tests

Submission Process

Primary Method: Electronic submission via Availity portal for fastest processing (1-3 days)

Alternative: Fax Premera's Pre-service/Prior Authorization Review Request form to:

  • Standard plans: 800-843-1114
  • Federal Employee Program: 866-948-8823

Required Form Elements:

  • Patient demographics and member ID
  • Provider NPI and tax ID
  • Clinical rationale with supporting documentation
  • Requested medication details (NDC, quantity, days supply)

Specialty Pharmacy Network

Premera requires Enbrel to be dispensed through designated specialty pharmacies:

In-Network Options:

  • Accredo (Express Scripts Specialty Pharmacy)
  • AllianceRx Walgreens Prime (select plans only)

Patient Enrollment Process:

  1. Doctor e-prescribes directly to specialty pharmacy
  2. Pharmacy contacts patient within 24-48 hours to schedule delivery
  3. Patient provides insurance information and delivery preferences
  4. Pharmacy coordinates with Premera for coverage verification
Tip: Save unknown phone numbers as contacts during this process, as specialty pharmacies often call from different numbers for scheduling and clinical consultations.

Step-by-Step Approval Process

Phase 1: Preparation (Patient & Provider)

  1. Gather medical records including previous treatment history, lab results, and imaging studies
  2. Schedule rheumatologist appointment to discuss Enbrel and complete necessary evaluations
  3. Complete safety screening including TB and hepatitis B testing

Phase 2: Submission (Provider)

  1. Complete PA form using Premera's electronic portal or downloadable PDF
  2. Submit clinical documentation supporting medical necessity and failed prior therapies
  3. Specify specialty pharmacy preference (Accredo or AllianceRx Walgreens Prime)

Phase 3: Review & Follow-up

  1. Track submission status through provider portal or by calling Premera pharmacy services
  2. Respond to requests for additional information within specified timeframes
  3. Coordinate with specialty pharmacy once approved for prescription fulfillment

Timeline Expectations:

  • Electronic submissions: 1-3 business days
  • Fax submissions: 3-5 business days
  • Complex cases: up to 14 business days
  • Expedited reviews: 72 hours for urgent medical situations

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Required Documentation
Step therapy not completed Document contraindications or failures of preferred agents Medical records showing adverse reactions, lack of efficacy, or clinical reasons why alternatives are inappropriate
Insufficient documentation of severity Provide objective disease activity measures DAS28 scores, joint counts, inflammatory markers, functional assessments
Missing safety screening Complete required testing TB screening results, hepatitis B panel, baseline labs
Inadequate trial duration Document appropriate treatment periods Pharmacy records, clinical notes showing 3+ month trials of DMARDs
Not medically necessary Strengthen clinical rationale Peer-reviewed literature, specialty society guidelines, FDA labeling information

Clinician Corner: Medical Necessity Letter Checklist

When preparing appeals or initial authorizations, ensure your letter includes:

  • Problem statement: Clear diagnosis with severity indicators
  • Prior treatments: Specific medications tried, dosages, duration, and outcomes
  • Clinical rationale: Why Enbrel is medically necessary for this patient
  • Guideline support: References to ACR, EULAR, or other relevant guidelines
  • Monitoring plan: How you'll assess safety and efficacy
  • Alternative considerations: Why other options are not suitable

Appeals Process in Washington

Washington State provides robust protections for patients facing insurance denials through a structured appeals process.

Internal Appeals (Required First Step)

Timeline: File within 180 days of denial notice Process: Submit appeal through Premera member portal or mail to address on denial letter Decision timeframe: 30 days for standard appeals, 72 hours for expedited

External Review (Independent Review)

If internal appeals are unsuccessful, Washington residents can request external review through the Office of the Insurance Commissioner (OIC).

Eligibility: Available after exhausting internal appeals for fully insured plans Timeline: Request within 4 months of final internal denial Process: Submit request to Washington State OIC or directly through your insurer Review timeframe: 45 days for standard review, 72 hours for expedited Cost: Free to consumers

Key advantages of Washington's external review:

  • Independent medical experts review your case
  • Decision is binding on the insurer
  • No cost to the patient
  • Strong track record of overturning inappropriate denials
Important: Self-insured employer plans (ERISA) are not subject to state external review and must use federal Department of Labor processes.

Cost-Saving Programs

Manufacturer Support Programs

ENBREL Co-Pay Program:

  • Potential $0 out-of-pocket costs per dose for commercially insured patients
  • No income restrictions
  • Enroll at enbrel.com/support
  • Provides RxBIN, PCN, Group, and Member ID for pharmacy use

Additional Resources

  • Patient assistance programs for uninsured or underinsured patients
  • Foundation grants through organizations like the Patient Access Network Foundation
  • State pharmaceutical assistance programs (check Washington State Department of Health resources)

When navigating complex insurance approvals, having expert support can make all the difference. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by providing evidence-backed documentation and targeted rebuttals aligned to each plan's specific requirements. Their platform streamlines the appeals process by identifying denial reasons and crafting point-by-point responses using the right clinical evidence and procedural requirements.

FAQ

How long does Blue Cross Blue Shield prior authorization take in Washington? Standard electronic submissions typically receive decisions within 1-3 business days, while fax submissions take 3-5 business days. Complex cases may require up to 14 business days. Expedited reviews for urgent medical situations are processed within 72 hours.

What if Enbrel is denied due to step therapy requirements? You can request a step therapy exception by documenting medical contraindications to preferred alternatives, previous failures of biosimilar agents, or clinical reasons why step therapy is inappropriate. Your rheumatologist should provide detailed medical records supporting the exception request.

Can I get an expedited appeal if my condition is worsening? Yes, Washington allows expedited appeals when delays could seriously jeopardize your health. Contact Premera immediately to request expedited review, and have your doctor provide documentation of medical urgency.

Does my HMO plan require a referral to see a rheumatologist for Enbrel? Most Premera HMO plans require a referral from your primary care physician before seeing a specialist. However, referral requirements can vary by specific plan, so check your Evidence of Coverage or call member services.

What happens if my external review is successful? If the Independent Review Organization overturns Premera's denial, the insurer must provide coverage retroactively from the original denial date. This decision is legally binding on the insurance company.

Are there income limits for the ENBREL Co-Pay Program? No, the manufacturer's co-pay program has no income restrictions for commercially insured patients. However, it cannot be used with government insurance programs like Medicare or Medicaid.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances, specific plan benefits, and medical necessity. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For additional help with insurance appeals in Washington, contact the Office of the Insurance Commissioner at 1-800-562-6900.

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