By Counterforce Health Team in Firdapse (amifampridine) —

How to Get Firdapse (Amifampridine) Covered by Blue Cross Blue Shield in New York: Forms, Appeals, and Success Strategies

Answer Box: Getting Firdapse Covered in New York

Eligibility: Firdapse (amifampridine) requires prior authorization from Blue Cross Blue Shield plans in New York for patients with confirmed Lambert-Eaton myasthenic syndrome (LEMS).

Fastest Path: Contact your BCBS member services to obtain the current prior authorization form, have your neurologist complete clinical documentation proving LEMS diagnosis with antibody testing and EMG results, then submit through your plan's specialty pharmacy network.

First Step Today: Call the member services number on your ID card to identify your specific BCBS plan type and get the correct PA form—requirements vary between Anthem, Excellus, and other New York Blues affiliates.

Table of Contents

  1. Start Here: Verify Your Plan
  2. Required Forms and Documentation
  3. Submission Portals and Methods
  4. Specialty Pharmacy Requirements
  5. Support Lines and Case Management
  6. Appeals Process in New York
  7. Common Denial Reasons and Solutions
  8. State Resources and Consumer Help
  9. FAQ: Firdapse Coverage Questions

Start Here: Verify Your Plan

Blue Cross Blue Shield operates through multiple independent plans in New York, each with different requirements for Firdapse coverage. Your specific plan determines which forms, submission methods, and specialty pharmacy networks apply to you.

Major BCBS Plans in New York

Anthem Blue Cross and Blue Shield

  • Member Services: 1-800-450-8753
  • Specialty drugs managed through CarelonRx
  • Uses Availity Portal for provider submissions

Excellus BlueCross BlueShield

  • Covers Western and Central New York regions
  • Coordinates specialty pharmacy through network partners
  • Provider portal available (verify current link)

Empire BlueCross BlueShield (Anthem)

  • Medicaid managed care plans
  • BioPlus Specialty Pharmacy for specialty drugs: 833-549-2115
Tip: Your member ID card shows your specific plan name. This determines which prior authorization forms and submission processes you'll need to follow.

Required Forms and Documentation

Prior Authorization Requirements

Prior authorization is required for Firdapse across BCBS New York plans to ensure appropriate use for LEMS patients.

Clinical Documentation Checklist

Your neurologist or neuromuscular specialist must provide:

Diagnosis Confirmation

  • Confirmed LEMS diagnosis with ICD-10 code G73.1
  • Voltage-gated calcium channel (VGCC) antibody testing results (85-95% of LEMS patients test positive)
  • Electrodiagnostic studies (EMG/nerve conduction) showing characteristic findings
  • Clinical evaluation documenting muscle weakness, autonomic dysfunction, and depressed reflexes

Treatment History

  • Documentation of prior therapies attempted (if any)
  • Contraindications to alternative treatments
  • Current medications and dosing requirements

Specialist Attestation

  • Prescription from neurologist or neuromuscular specialist
  • Medical necessity letter explaining why Firdapse is appropriate
  • Treatment goals and monitoring plan
Note: Specimen collection for antibody testing should occur before starting immunosuppressant therapy, as these medications can reduce diagnostic sensitivity.

Submission Portals and Methods

Anthem Blue Cross Blue Shield Submissions

Provider Portal: Availity Portal for electronic submissions Phone: 1-800-450-8753 (accepts PA requests 24/7) Fax: 1-800-964-3627 for medical prior authorization

Specialty Pharmacy Coordination

CarelonRx (for most Anthem plans)

  • Prior authorization: 833-293-0659 or fax 844-521-6940
  • Specialty pharmacy: 833-549-2874 or fax 800-269-5493

BioPlus Specialty Pharmacy (Medicaid)

  • Phone: 833-549-2115 (available 24/7)
  • Provides medication management and side effect support

Timeline Expectations

  • Standard review: 5-15 business days
  • Expedited review: 24-72 hours for urgent cases
  • Additional information requests: Can extend timeline by 5-10 days

Specialty Pharmacy Requirements

Most BCBS plans in New York require Firdapse to be dispensed through their specialty pharmacy network due to the medication's complexity and cost (retail cash prices around $28,800 per month).

Onboarding Steps

  1. Prior authorization approval must be obtained first
  2. Prescription transfer from retail pharmacy to specialty network
  3. Patient enrollment with specialty pharmacy for ongoing support
  4. Delivery coordination for home shipment (typically every 30 days)

Benefits of Specialty Pharmacy

  • Clinical pharmacist consultations for dosing optimization
  • Side effect monitoring and management
  • Coordination with your neurologist
  • Insurance benefits verification and copay assistance programs

Support Lines and Case Management

Member Services Contacts

Anthem BCBS New York

  • Member Services: 1-800-450-8753
  • 24/7 NurseLine: 1-800-300-8181 (TTY: 711)
  • Case Management referrals through Provider Services

General BCBS Support

  • Call the member services number on your ID card
  • Have your member ID, prescription details, and doctor information ready

Case Management Services

BCBS case managers can help coordinate care for complex conditions like LEMS. They work with your medical team to:

  • Prevent hospital readmissions
  • Coordinate between specialists
  • Navigate insurance requirements
  • Connect you with additional resources

To request case management support, contact your plan's member services or have your provider call the provider services line.

Appeals Process in New York

If your Firdapse prior authorization is denied, New York provides robust appeal rights through multiple levels.

Internal Appeals (First Level)

Timeline: File within 180 days of denial for commercial plans Process: Submit appeal through your BCBS plan's standard process Documentation: Include denial letter, medical records, and physician support letter

External Appeals Through New York DFS

New York's external appeal process is particularly strong for specialty drug denials.

Contact: New York State Department of Financial Services at 1-800-400-8882 Timeline: 4 months from final adverse determination (recently extended from 60 days) Fee: Maximum $25 per appeal (waived for Medicaid or financial hardship) Expedited Process: 24-hour decisions for non-formulary drug denials

Key Advantage: If the external reviewer overturns the denial, your health plan must cover Firdapse and refund your appeal fee.

Additional Support

Community Health Advocates: 888-614-5400 (free counseling on insurance denials) Healthcare Appeals Ombudsman: 1-800-NYS-APPEAL (free assistance with complex appeals)

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
Lack of confirmed LEMS diagnosis Provide comprehensive diagnostic workup VGCC antibodies, EMG results, specialist evaluation
Missing specialist prescription Obtain neurologist or neuromuscular specialist Rx Board-certified specialist attestation
Exceeding dose limits Justify higher doses with clinical rationale Treatment response documentation, specialist letter
Contraindications (seizure history) Document risk-benefit analysis Neurology consultation, seizure history review
Incomplete trial of alternatives Explain why alternatives are inappropriate Contraindications, prior failures, specialist rationale

Medical Necessity Letter Key Points

Your neurologist should address:

  • Confirmed LEMS diagnosis with supporting test results
  • Why Firdapse is the appropriate first-line treatment
  • Expected clinical benefits and monitoring plan
  • Any contraindications to alternative therapies

State Resources and Consumer Help

New York provides extensive consumer protection for insurance appeals, particularly valuable for expensive specialty drugs like Firdapse.

Key Resources

New York State Department of Financial Services

Community Health Advocates

Consumer Assistance Program

  • Independent counseling on insurance denials
  • Help with filing appeals and understanding coverage rights

Clinician Corner: Medical Necessity Documentation

Healthcare providers play a crucial role in securing Firdapse approval. Your medical necessity letter should include:

Essential Clinical Elements

  1. Diagnosis Documentation
    • LEMS confirmed with VGCC antibody testing (positive in 85-95% of cases)
    • EMG/nerve conduction studies showing characteristic patterns
    • Clinical triad: proximal weakness, autonomic dysfunction, depressed reflexes
  2. Treatment Rationale
  3. Monitoring Plan
    • Regular neurological assessments
    • Seizure risk monitoring (contraindication)
    • Functional improvement measurements

Supporting Literature

Reference authoritative sources in your letter:

  • FDA prescribing information for Firdapse
  • Neuromuscular society treatment guidelines
  • Peer-reviewed studies on LEMS management

FAQ: Firdapse Coverage Questions

Q: How long does BCBS prior authorization take in New York? A: Standard review takes 5-15 business days. Expedited reviews for urgent cases may be completed within 24-72 hours. Contact your plan for expedited processing if medically urgent.

Q: What if Firdapse is non-formulary on my plan? A: You can request a formulary exception with medical necessity documentation. New York allows expedited external appeals for non-formulary drugs with 24-hour decision timelines.

Q: Can I request an expedited appeal? A: Yes. New York provides expedited external appeals for specialty drugs, with decisions required within 24 hours for non-formulary medications and 72 hours for other urgent appeals.

Q: Does step therapy apply to Firdapse? A: Step therapy requirements vary by plan. If required to try alternatives first, your neurologist can request an exception based on contraindications or medical appropriateness of Firdapse as first-line therapy.

Q: What if I move from another state where I was already taking Firdapse? A: Document your current treatment and clinical response. Continuity of care provisions may help maintain coverage during the transition to a New York BCBS plan.

Q: Are there financial assistance programs available? A: Yes. Catalyst Pharmaceuticals offers patient assistance programs. Contact their patient services for eligibility requirements and application process.

When Treatment Access Gets Complex

Navigating insurance approval for rare disease medications like Firdapse can be overwhelming, especially when dealing with complex prior authorization requirements and potential appeals. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each plan's specific requirements.

For patients and clinicians facing Firdapse denials, having expert support can make the difference between prolonged delays and successful approval. The platform helps identify the specific denial basis—whether PA criteria, step therapy, or medical necessity challenges—and provides the clinical documentation and evidence citations needed for effective appeals.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and requirements change frequently. Always verify current requirements with your specific Blue Cross Blue Shield plan and consult with your healthcare provider regarding appropriate treatment decisions. For personalized assistance with insurance appeals and coverage issues, contact the New York State Department of Financial Services or Community Health Advocates.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.