By Counterforce Health Team in Firdapse (amifampridine) —

How to Get Firdapse (amifampridine) Covered by Blue Cross Blue Shield in Washington: Complete Prior Authorization and Appeals Guide

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

Firdapse (amifampridine) requires prior authorization from Blue Cross Blue Shield plans in Washington for Lambert-Eaton myasthenic syndrome (LEMS). To get approval: (1) Ensure confirmed LEMS diagnosis with EMG and anti-VGCC antibodies by a neuromuscular specialist, (2) Submit PA request through your provider with complete clinical documentation, and (3) If denied, file internal appeal within 180 days, then external IRO review within 60 days for binding decision. Success rates: 70-78% for internal appeals with strong evidence, 40-45% for external reviews.

First step today: Contact your prescribing neurologist to verify you have complete LEMS diagnostic workup (EMG with increment >60%, anti-P/Q VGCC antibodies) and request they submit prior authorization to your specific Blue Cross Blue Shield plan.

Table of Contents

  1. How to Use This Guide
  2. Eligibility Triage: Do You Qualify?
  3. If You're Likely Eligible: Document Checklist
  4. If You're Possibly Eligible: Tests to Complete
  5. If Not Yet Eligible: Alternative Options
  6. If Denied: Washington Appeals Process
  7. Common Denial Reasons & Solutions
  8. Costs & Patient Assistance
  9. Frequently Asked Questions

How to Use This Guide

This guide helps Washington residents navigate Blue Cross Blue Shield's prior authorization process for Firdapse (amifampridine), the only FDA-approved treatment for Lambert-Eaton myasthenic syndrome (LEMS). Whether you have Premera Blue Cross, Regence BlueShield, or another Blue plan, the core requirements are similar.

Start with the eligibility triage below to determine your next steps. If you're unsure about your diagnosis or need additional testing, discuss with your neurologist first.

Note: This guide covers fully-insured Blue Cross Blue Shield plans. If you have a self-funded employer plan, some timelines may differ—contact your benefits administrator for specifics.

Eligibility Triage: Do You Qualify?

✅ Likely Eligible (Proceed to Document Checklist)

  • Age: 6 years or older
  • Confirmed LEMS diagnosis by neuromuscular specialist with:
    • Characteristic clinical triad (proximal weakness, autonomic symptoms, hyporeflexia with post-exercise improvement)
    • EMG showing increment >60% on high-frequency stimulation or post-exercise
    • Anti-P/Q VGCC antibodies positive (found in 85-90% of cases)
  • Failed or contraindicated alternatives like pyridostigmine
  • No seizure history (absolute contraindication per FDA prescribing information)

🟡 Possibly Eligible (Complete Additional Testing)

  • LEMS symptoms present but incomplete diagnostic workup
  • Awaiting EMG or antibody results
  • Seeing general neurologist (may need neuromuscular specialist referral)
  • Under age 6 (requires individual consideration)

❌ Not Yet Eligible (Explore Alternatives First)

  • No confirmed LEMS diagnosis
  • Haven't tried first-line supportive therapies
  • Active seizure disorder
  • Using for off-label conditions

If You're Likely Eligible: Document Checklist

Before your provider submits the prior authorization, ensure these documents are ready:

Required Clinical Documentation

Document Type What's Needed Where to Get It
LEMS Diagnosis Confirmation EMG report showing >60% increment; anti-VGCC antibody results Neuromuscular specialist
Specialist Attestation Letter from neurologist confirming LEMS diagnosis and need for Firdapse Prescribing physician
Prior Therapy Documentation Records of failed/contraindicated alternatives (pyridostigmine, IVIG, immunosuppressants) Medical records
Functional Assessment Description of current symptoms and functional limitations Provider notes
Dosing Plan Proposed starting dose and titration schedule per FDA guidelines Prescribing physician

Submission Process

  1. Provider submits PA request through Blue Cross Blue Shield provider portal or fax
  2. Standard timeline: 72 hours to 7 days for determination
  3. Expedited option available if delay would jeopardize health (24-72 hours)
Tip: Ask your provider to mark the request as expedited if your LEMS symptoms are rapidly worsening or significantly impacting daily function.

If You're Possibly Eligible: Tests to Complete

Work with your neurologist to complete the diagnostic workup:

Essential Tests for LEMS Confirmation

  1. Electromyography (EMG) with repetitive nerve stimulation
  2. Anti-P/Q VGCC antibody testing
    • Radioimmunoprecipitation assay (RIA)
    • Available through Mayo Clinic Labs and other reference labs
  3. Cancer screening (if not already done)
    • Chest CT to rule out small cell lung cancer
    • ~50-60% of LEMS cases are paraneoplastic

Timeline for Re-application

  • Allow 2-4 weeks for test results
  • Schedule follow-up with neuromuscular specialist to review results
  • Resubmit PA request once diagnostic criteria are met

If Not Yet Eligible: Alternative Options

Symptomatic Treatments to Try First

Many Blue Cross Blue Shield plans require trial of these alternatives before approving Firdapse:

  • Pyridostigmine (Mestinon): First-line cholinesterase inhibitor
  • IVIG or plasmapheresis: For severe cases or acute exacerbations
  • Immunosuppressants: Corticosteroids, azathioprine for autoimmune LEMS

Preparing for Exception Requests

Document why standard treatments aren't appropriate:

  • Contraindications: Allergies, drug interactions, comorbidities
  • Treatment failures: Lack of response, intolerable side effects
  • Disease severity: Functional impairment despite maximum tolerated therapy

If Denied: Washington Appeals Process

Washington state provides robust appeal rights through multiple levels. Counterforce Health specializes in turning insurance denials into successful appeals by crafting evidence-backed rebuttals that address each plan's specific criteria.

Level 1: Internal Appeal

  • Deadline: Within 180 days of denial notice
  • Decision time: 30 days (72 hours if expedited)
  • How to file: Submit through Blue Cross Blue Shield member portal, fax, or mail
  • Success rate: 70-78% with comprehensive clinical evidence

Required documents:

  • Original denial letter
  • Additional medical evidence not in original PA
  • Updated clinical notes showing disease progression or treatment failures

Level 2: External Review (IRO)

If internal appeal fails, Washington's Independent Review Organization process provides an impartial review:

  • Deadline: Within 60 days of final internal denial
  • Decision time: 20 days for fully-insured plans (45 days for self-insured)
  • Cost: Free to you
  • Success rate: 40-45% for specialty medications in Washington
  • Contact: Submit through your insurer, who notifies Washington Office of Insurance Commissioner

Key advantage: IRO decision is binding on your insurer—they must provide coverage if overturned.

Washington-Specific Resources

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Evidence
"Not medically necessary" Submit updated clinical notes showing functional impairment Detailed symptom documentation, quality of life impact
"Experimental/investigational" Cite FDA approval for LEMS FDA approval letter, peer-reviewed studies
"Must try alternatives first" Document prior therapy failures Medical records showing pyridostigmine trial, side effects, contraindications
"Insufficient diagnostic evidence" Provide complete EMG and antibody results EMG report with >60% increment, positive anti-VGCC antibodies
"Seizure risk" Confirm no seizure history Neurology consultation confirming seizure-free status

Costs & Patient Assistance

Firdapse Pricing and Support

  • Estimated annual cost: $300,000-$375,000 without insurance
  • Monthly out-of-pocket: Varies by plan; specialty tier typically $100-$500+ copay

Financial Assistance Options

  1. Catalyst Cares Patient Support Program
  2. Foundation Grants
    • Patient Advocate Foundation
    • HealthWell Foundation (when funds available)
  3. State Programs

Frequently Asked Questions

How long does Blue Cross Blue Shield prior authorization take in Washington?

Standard PA decisions are made within 72 hours to 7 days. Expedited requests (when delay would jeopardize health) receive decisions within 24-72 hours. Source: Premera BCBS policy guidelines

What if Firdapse is non-formulary on my plan?

You can request a formulary exception. Provide evidence that formulary alternatives (like pyridostigmine) are ineffective or contraindicated. The process follows the same PA timeline.

Can I request an expedited appeal in Washington?

Yes, if standard timelines would seriously jeopardize your health. Expedited appeals receive decisions within 72 hours. Contact your plan directly to request expedited status.

Does step therapy apply if I tried alternatives outside Washington?

Yes, documented treatment failures from any provider count toward step therapy requirements. Ensure your current provider has complete records of prior therapies.

What happens if the IRO denies my appeal?

IRO decisions are final for the external review process. You may still contact the Washington OIC for guidance or consider legal consultation, but the external review is typically the last step in appeals.

How do I verify my specific Blue Cross Blue Shield plan's requirements?

Check your plan's formulary using your Rx Plan number from your ID card. Premera members can use their Drugs Requiring Approval tool. Regence members should contact customer service for plan-specific criteria.

From Our Advocates

We've seen many Washington patients successfully obtain Firdapse coverage after initial denials. The key is comprehensive documentation—EMG results showing the characteristic increment, positive antibody tests, and clear evidence of functional impairment. When insurers understand that Firdapse is the only FDA-approved treatment for confirmed LEMS, and that delays can worsen this progressive condition, approval rates improve significantly. Don't be discouraged by an initial denial; the appeals process in Washington is designed to protect patients' access to necessary treatments.

When to Contact Counterforce Health

If you're facing a complex denial or need help crafting a compelling appeal, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes your specific denial reason and plan policies to create point-by-point rebuttals that address each insurer's criteria, increasing your chances of approval.

Sources & Further Reading

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

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