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

How to Get Enhertu Covered by Blue Cross Blue Shield in Georgia: Complete Guide to Prior Authorization, Appeals, and Forms

Answer Box: Getting Enhertu Approved in Georgia

Blue Cross Blue Shield of Georgia requires prior authorization for Enhertu® (fam-trastuzumab deruxtecan-nxki) with mandatory HER2 testing documentation. Submit your PA request through the Availity provider portal or call member services at the number on your ID card. If denied, you have 180 days for internal appeals, then 60 days for external review through the Georgia Department of Insurance.

First step today: Verify your HER2 test results are FDA-approved/CLIA-compliant and gather prior therapy documentation before your oncologist submits the PA request.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Required Forms and Documentation
  4. Submission Portals and Contact Information
  5. Common Denial Reasons and Solutions
  6. Appeals Process for Georgia Residents
  7. Specialty Pharmacy Enrollment
  8. Cost Support and Patient Assistance
  9. When to Contact Georgia Regulators
  10. Frequently Asked Questions

Coverage Requirements at a Glance

Requirement Details Documentation Needed
Prior Authorization Required for all indications Complete PA form via Availity
HER2 Testing FDA-approved/CLIA-compliant test IHC 3+ OR FISH/ISH ≥2.0 with IHC 2+
Age Limit ≥18 years old Date of birth verification
Cardiac Monitoring LVEF within normal limits Baseline and q3 month ECHO/MUGA
Single Agent Use No combination restrictions Prescriber attestation
Site of Care Physician office preferred Avoid hospital outpatient penalties

Source: Prime Therapeutics IC-0522 policy

Step-by-Step: Fastest Path to Approval

1. Verify Your Plan Coverage

Who: Patient
Action: Log into your Anthem member portal or call the number on your ID card
Timeline: 5-10 minutes
What to check: Formulary tier, specialty pharmacy requirements, current PA status

2. Gather Required Test Results

Who: Patient/Oncologist
Action: Obtain HER2 testing documentation from pathology lab
Timeline: 1-3 business days
Required: IHC 3+ OR FISH/ISH ratio ≥2.0 with concurrent IHC 2+ for HER2-positive tumors

3. Document Prior Therapies

Who: Oncologist
Action: Compile treatment history showing progression or intolerance
Timeline: Same day
Include: Dates, drug names, response, reason for discontinuation

4. Submit Prior Authorization

Who: Oncologist/Staff
Action: Complete PA via Availity portal or fax to plan-specific number
Timeline: Electronic submission preferred for fastest processing
Attach: HER2 results, LVEF documentation, clinical notes

5. Follow Up on Decision

Who: Patient/Clinic
Action: Check portal or call member services for status updates
Timeline: Standard review 15 business days; expedited 72 hours
Next steps: If approved, coordinate with specialty pharmacy; if denied, prepare appeal

Required Forms and Documentation

Primary Prior Authorization Form

Blue Cross Blue Shield of Georgia uses the Prime Therapeutics medical prior authorization form for Enhertu requests. Access the current version through:

  • Availity provider portal (preferred)
  • Member services at 1-855-641-4862 (State Health Benefit Plan)
  • General inquiries: 1-404-842-8000

Essential Documentation Checklist

✅ HER2 Test Results - FDA-approved/CLIA-compliant laboratory report
✅ LVEF Assessment - Baseline echocardiogram or MUGA scan
✅ Prior Therapy Records - Complete treatment history with outcomes
✅ Pathology Report - Confirming diagnosis and tumor characteristics
✅ Clinical Notes - Oncologist's medical necessity justification
✅ Insurance Card Copy - Front and back for benefit verification

Clinician Corner: Your medical necessity letter should specifically address why covered alternatives (trastuzumab, pertuzumab, T-DM1) are inappropriate. Reference NCCN Guidelines v4.2025 and include specific ICD-10 codes for the patient's cancer type.

Submission Portals and Contact Information

Electronic Submission (Fastest)

  • Availity Portal: www.availity.com
  • Provider Support: 800-282-4548 (Mon-Fri 5 a.m.-5 p.m. PT)
  • Features: Real-time eligibility, PA status tracking, secure messaging

Phone Numbers by Plan Type

Plan Type Member Services Provider Line
State Health Benefit Plan 1-855-641-4862 Same number
FEHB Plans 1-800-282-2473 1-800-860-2156 (precert)
Individual/Family (under 65) 1-844-285-5164 Via Availity
Medicare Plans 1-855-745-4397 Seasonal hours

Always check your member ID card for the most current number

Specialty Pharmacy Benefits

  • Medical Benefit Inquiries: 800-274-7767 (Mon-Fri 7:30 a.m.-5 p.m. PT)
  • Pharmacy Benefits: 800-700-2541 (Mon-Fri 8 a.m.-5 p.m. PT)
  • Fax for Medical Benefit: 866-408-7195

Common Denial Reasons and Solutions

Denial Reason Solution Strategy Required Documentation
Missing HER2 Status Submit FDA-approved test results IHC/FISH pathology report
Step Therapy Not Met Document prior therapy failures Treatment records with dates/outcomes
Not Medically Necessary Provide clinical justification Oncologist letter citing NCCN guidelines
Site of Care Restriction Request physician office administration Administrative appeal with cost comparison
Quantity/Dosing Limits Justify weight-based dosing BSA calculation and dosing rationale
Tip: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing the denial letter, plan policy, and clinical notes to draft point-by-point rebuttals aligned to the plan's own rules.

Appeals Process for Georgia Residents

Level 1: Internal Appeal

Deadline: 180 days from denial notice
Timeline: 30 days standard; 72 hours expedited
How to Submit:

  • Online via member portal
  • Mail to address on denial letter
  • Fax to plan-specific number

Required Elements:

  • Copy of denial letter
  • Medical necessity letter from oncologist
  • All supporting clinical documentation
  • Request for expedited review if applicable

Level 2: External Review (Georgia DOI)

Deadline: 60 days from final internal denial
Cost: Free to patient
Timeline: 30 business days standard; 72 hours expedited

How to Submit:

  1. Complete Georgia DOI external review form
  2. Mail to: Georgia Department of Insurance, Consumer Services Division
  3. Call 1-800-656-2298 for assistance

Key Advantage: Decision is binding on the insurer if approved

Note: Georgia allows concurrent external review filing with expedited internal appeals if delay poses serious health risk.

Specialty Pharmacy Enrollment

Enhertu requires fulfillment through BCBS Georgia's in-network specialty pharmacies:

Approved Specialty Pharmacies

  • CVS Specialty (for medical benefit infusions)
  • BioPlus Specialty Pharmacy
  • CenterWell Pharmacy

Enrollment Process

  1. Verify Network Status - Check your specific plan's specialty pharmacy list
  2. Prescription Transfer - Oncologist sends prescription to chosen pharmacy
  3. Benefits Verification - Pharmacy confirms coverage and copay
  4. Patient Registration - Complete enrollment forms and delivery preferences
  5. Care Coordination - Pharmacy schedules delivery/administration

Contact: Call pharmacy member services at the number on your ID card to initiate enrollment

Cost Support and Patient Assistance

Manufacturer Support

  • Daiichi Sankyo Patient Assistance: Check eligibility at manufacturer website
  • Copay Cards: May reduce out-of-pocket costs for eligible patients
  • Income Requirements: Typically 400% of Federal Poverty Level

Additional Resources

  • Georgia Cancer Coalition: Local support programs
  • Patient Advocate Foundation: Copay relief program
  • CancerCare: Financial assistance and case management
Important: Copay assistance programs may not apply to government insurance plans (Medicare, Medicaid)

When to Contact Georgia Regulators

Contact the Georgia Department of Insurance if:

  • Your external review deadline is approaching
  • The insurer isn't following proper procedures
  • You need help understanding your appeal rights

Georgia DOI Consumer Services:

Additional Support:

  • Georgians for a Healthy Future: Consumer assistance organization
  • Georgia Legal Services Program: For Medicaid/low-income appeals

For urgent situations where treatment delay could cause serious harm, Counterforce Health can help expedite the appeals process by providing evidence-backed documentation that meets payer-specific requirements.

Frequently Asked Questions

Q: How long does BCBS Georgia prior authorization take for Enhertu? A: Standard review takes up to 15 business days; expedited review (if medically urgent) takes 72 hours. Electronic submission via Availity is fastest.

Q: What if Enhertu isn't on my formulary? A: Request a formulary exception by documenting medical necessity and why covered alternatives won't work. Include prior therapy failures and contraindications.

Q: Can I get an expedited appeal in Georgia? A: Yes, if treatment delay would jeopardize your health. Your doctor must certify the urgency. Both internal and external reviews offer expedited options.

Q: What HER2 testing is required for approval? A: FDA-approved or CLIA-compliant tests showing IHC 3+ OR FISH/ISH ratio ≥2.0 with concurrent IHC 2+ for HER2-positive indications. HER2-low requires specific testing per NCCN guidelines.

Q: Does step therapy apply to Enhertu? A: It depends on your specific indication and prior treatments. Document any failed therapies (trastuzumab, pertuzumab, T-DM1) with dates and reasons for discontinuation.

Q: What if I miss the 60-day external review deadline? A: Contact Georgia DOI immediately at 1-800-656-2298. While options are limited, they may provide guidance or accept late filings in exceptional circumstances.

Q: Can I appeal a site-of-care denial? A: Yes, request physician office administration by demonstrating medical necessity or cost-effectiveness compared to hospital outpatient settings.

Q: Is cardiac monitoring covered during Enhertu treatment? A: LVEF monitoring every 3 months is typically covered as part of standard cancer care. Verify specific coverage with your plan.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for personalized guidance. Coverage policies and procedures may change; verify current requirements with your specific Blue Cross Blue Shield plan.

Sources & Further Reading

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