By Counterforce Health Team in Enhertu (fam-trastuzumab deruxtecan-nxki) —

How to Get Enhertu Approved by Blue Cross Blue Shield of Illinois: Complete Prior Authorization Guide (2025)

Answer Box: Getting Enhertu Covered by Blue Cross Blue Shield Illinois

Enhertu requires prior authorization from Blue Cross Blue Shield of Illinois (BCBSIL). The fastest path to approval: 1) Verify your HER2 testing documentation is complete, 2) Submit the medical prior authorization form with ILD monitoring plan, and 3) Use Accredo Specialty Pharmacy for distribution. Appeals must be filed within 60 days if denied, with external review available through Illinois Department of Insurance. Start today by downloading the PA form from your BCBSIL provider portal.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Plan Verification
  3. Gather Required Documentation
  4. Submit Your Prior Authorization
  5. Follow-Up and Timelines
  6. If You Need More Information
  7. If You're Denied: Appeals Process
  8. Renewal and Re-Authorization
  9. Costs and Patient Support
  10. Quick Reference Checklist
  11. Frequently Asked Questions

What This Guide Covers

This comprehensive guide helps patients, caregivers, and healthcare providers navigate the prior authorization process for Enhertu (fam-trastuzumab deruxtecan-nxki) with Blue Cross Blue Shield of Illinois. Whether you're dealing with HER2-positive breast cancer, gastric cancer, or lung cancer, we'll walk you through every step—from initial submission to appeals if needed.

Who this helps:

  • Patients prescribed Enhertu by their oncologist
  • Family members managing insurance appeals
  • Healthcare providers and office staff
  • Specialty pharmacy coordinators

You'll learn the exact forms to use, required documentation, typical approval timelines, and what to do if your request is denied.

Before You Start: Plan Verification

Confirm Your Coverage Type

BCBSIL offers multiple plan types, each with different requirements:

  • Commercial plans (employer-sponsored)
  • Individual marketplace plans
  • Medicaid managed care (Blue Cross Community Health Plans)
  • Medicare Advantage
Tip: Check your member ID card—the plan type affects which forms you'll need and processing timelines.

Verify Network Status

Enhertu must be administered at an in-network facility. BCBSIL typically covers infusions at:

  • Physician offices
  • Outpatient infusion centers
  • Hospital outpatient departments (may require additional approval)

Formulary and Benefit Check

Enhertu is covered under the medical benefit (not pharmacy benefit) for most BCBSIL plans. The medication requires:

  • Prior authorization for all indications
  • Administration through Accredo Specialty Pharmacy network
  • Documented HER2 testing for FDA-approved uses

Gather Required Documentation

Essential Clinical Information

HER2 Testing Documentation:

  • Laboratory report showing HER2 status (IHC 3+ or ISH amplified)
  • Date of testing and methodology used
  • Pathology report with diagnosis and staging

Medical History:

  • Complete diagnosis with ICD-10 codes
  • Documentation of prior therapies and outcomes
  • Contraindications to alternative treatments
  • Current performance status

ILD Monitoring Plan: Enhertu carries a boxed warning for interstitial lung disease. Your submission must include:

  • Baseline chest imaging (HRCT recommended)
  • Plan for regular monitoring (every 12 weeks minimum)
  • Patient education documentation
  • Pulmonologist consultation plan if needed

Required Forms

Download the current BCBSIL Medical Prior Authorization Form from:

Note: Forms are updated regularly. Always use the most current version to avoid processing delays.

Submit Your Prior Authorization

Coverage at a Glance

Requirement Details Source
Prior Authorization Required for all plans BCBSIL PA Code Lists
HER2 Testing Must document positive status FDA Label Requirements
Specialty Pharmacy Accredo network preferred BCBSIL Specialty Benefits
ILD Monitoring Required safety plan FDA Boxed Warning
Appeal Deadline 60 days from denial BCBSIL Appeals Process

Step-by-Step Submission Process

1. Complete the PA Form (Provider/Office Staff)

  • Fill all required fields completely
  • Attach clinical documentation
  • Include ILD monitoring protocol
  • Expected time: 30-45 minutes

2. Submit Through Preferred Channel

  • Electronic: BCBSIL provider portal (fastest)
  • Fax: Check current form for number
  • Mail: Include tracking for paper submissions
  • Expected processing: 15 business days

3. Coordinate with Specialty Pharmacy

  • Contact Accredo at time of submission
  • Provide prescription and PA reference number
  • Confirm delivery logistics with patient

4. Document Everything

  • Keep copies of all submissions
  • Record reference numbers and dates
  • Note contact person names

Follow-Up and Timelines

Standard Processing Times

  • Acknowledgment: 3 business days
  • Standard decision: 15 business days
  • Expedited decision: 24 hours (for urgent cases)
  • Extension possible: Up to 14 additional days with notification

When to Follow Up

Day 5: Confirm receipt if no acknowledgment received Day 10: Status check if no decision yet Day 16: Escalate if past standard timeline

Sample Follow-Up Script

"I'm calling about prior authorization request #[number] for patient [name] for Enhertu. The submission was [date]. Can you provide a status update and expected decision date?"

If You Need More Information

Common Information Requests

Medical Necessity Questions:

  • Additional clinical notes
  • Specialist consultation reports
  • Treatment response documentation
  • Quality of life assessments

Safety Monitoring:

  • Updated ILD screening results
  • Pulmonary function tests
  • Patient education confirmation
Clinician Corner: When responding to medical necessity requests, reference specific NCCN Guidelines and FDA labeling. Include patient-specific factors that support Enhertu over alternatives.

If You're Denied: Appeals Process

Illinois Appeals Timeline

Level Deadline Decision Time How to File
Internal Appeal 60 days from denial 15 business days Phone: 877-860-2837
Fax: 866-643-7069
Expedited Appeal 60 days from denial 24 hours Fax: 800-338-2227
External Review 4 months from final denial 5 business days Illinois Department of Insurance

Common Denial Reasons and Solutions

"HER2 testing not documented"

  • Solution: Submit complete pathology report with IHC/ISH results

"ILD monitoring plan insufficient"

  • Solution: Provide detailed protocol with imaging schedule and specialist contacts

"Alternative treatments not tried"

  • Solution: Document contraindications or failures with prior HER2-targeted therapies

Appeal Letter Template

Include these elements in your appeal:

  1. Patient identification and denial reference number
  2. Specific denial reason being challenged
  3. Clinical evidence supporting medical necessity
  4. Relevant guidelines and literature citations
  5. Request for expedited review if applicable

For complex appeals, organizations like Counterforce Health specialize in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and drafting point-by-point rebuttals aligned to each plan's specific requirements.

Renewal and Re-Authorization

When to Resubmit

Most approvals are granted for:

  • Initial approval: 6 months to 1 year
  • Continuation: Based on treatment response
  • Calendar reminder: Set for 30 days before expiration

Documentation for Renewal

  • Treatment response assessment
  • Updated imaging results
  • Toxicity evaluation
  • Continued medical necessity justification

Costs and Patient Support

Financial Assistance Options

Manufacturer Support:

  • Enhertu Co-pay Program (verify eligibility requirements)
  • Patient assistance programs for uninsured/underinsured

Foundation Grants:

  • CancerCare Co-Payment Assistance Foundation
  • Patient Advocate Foundation
  • Leukemia & Lymphoma Society

State Resources:

  • Illinois Department of Insurance consumer assistance: 877-527-9431
  • Illinois Attorney General Health Care Bureau: 877-305-5145

Quick Reference Checklist

Before Submitting:

  • Current BCBSIL PA form completed
  • HER2 testing results attached
  • ILD monitoring plan documented
  • Prior therapy documentation included
  • Specialty pharmacy contacted
  • Patient consent forms signed

After Submission:

  • Reference number recorded
  • Follow-up calendar reminders set
  • Patient notified of timeline
  • Backup appeal strategy prepared

If Denied:

  • Appeal filed within 60 days
  • Additional evidence gathered
  • External review option researched
  • Patient support resources contacted

Frequently Asked Questions

How long does BCBSIL prior authorization take for Enhertu? Standard processing is 15 business days, with expedited decisions available in 24 hours for urgent medical situations.

What if Enhertu isn't on my formulary? Enhertu is typically covered under medical benefits rather than pharmacy benefits. Request a formulary exception with supporting clinical documentation.

Can I request an expedited appeal in Illinois? Yes, expedited appeals are available for urgent medical situations and must be decided within 24 hours of receiving complete information.

Does step therapy apply to Enhertu? Step therapy requirements vary by plan and indication. Document any contraindications or failures with required first-line treatments.

What if my oncologist isn't in the BCBSIL network? You may need a referral or prior authorization for out-of-network specialists. Consider in-network alternatives or request a network adequacy exception.

How do I file an external review in Illinois? Contact the Illinois Department of Insurance within 4 months of your final internal appeal denial.

What documentation do I need for ILD monitoring? Include baseline chest imaging, monitoring schedule (every 12 weeks minimum), patient education confirmation, and emergency response plan.

Are there copay assistance programs for Enhertu? Check the manufacturer's website for current copay programs and eligibility requirements.

Sources & Further Reading

Disclaimer: This guide is for informational purposes only and does not constitute medical or legal advice. Insurance policies and requirements change frequently. Always verify current information with your specific plan and healthcare providers. For personalized assistance with complex appeals, consider consulting with healthcare coverage specialists like Counterforce Health, who help patients and providers navigate insurance denials with targeted, evidence-based appeal strategies.

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