By Counterforce Health Team in HyperHEP (hepatitis B immune globulin) —

How to Get HyperHEP Covered by Blue Cross Blue Shield of Texas: Forms, Appeals & Contact Guide 2025

Answer Box: Getting HyperHEP Covered by BCBS Texas

Quick Path to Coverage: Most Blue Cross Blue Shield of Texas (BCBSTX) plans cover HyperHEP (hepatitis B immune globulin) for post-exposure prophylaxis when administered within 24 hours of exposure. HealthSelect members need no prior authorization as of September 2024, but require a PCP referral. Commercial plan members should verify PA requirements through Availity Essentials portal first.

First Step Today: Call the number on your BCBSTX member ID card to confirm your specific plan's requirements, then have your provider check current PA status and order through Accredo Pharmacy if needed.

Table of Contents

  1. Start Here: Verify Your Plan Coverage
  2. Forms You'll Need
  3. Submission Portals & Electronic Systems
  4. Fax Numbers & Mailing Addresses
  5. Specialty Pharmacy Network
  6. Support Phone Lines
  7. Appeals Process
  8. Texas Regulatory Assistance
  9. FAQ

Start Here: Verify Your Plan Coverage

Before requesting HyperHEP, determine which BCBSTX plan you have, as requirements vary significantly:

HealthSelect Members (State Employees)

  • No prior authorization required for HyperHEP as of September 1, 2024
  • PCP referral required for in-network benefits
  • Coverage includes post-exposure prophylaxis per CDC guidelines

Commercial/Fully Insured Plans

  • Prior authorization may be required depending on your specific group plan
  • Check the current PA code list for HCPCS code J1460 (HyperHEP)
  • Requirements updated regularly, with changes effective January 1, 2025
Tip: Your member ID card shows your plan type. HealthSelect cards clearly indicate state employee coverage.

Forms You'll Need

Prior Authorization Forms (If Required)

  • TX Standard Prescription Drugs Prior Authorization Form - Submit via CoverMyMeds portal
  • Include complete clinical documentation:
    • Hepatitis B exposure details and timing
    • Patient's vaccination history and antibody status
    • Medical necessity justification
    • Provider attestation

Medical Necessity Documentation

Your provider should include:

  • Exposure event details (needlestick, sexual contact, perinatal)
  • Timing of exposure (within 24 hours preferred, up to 7 days for needlestick)
  • Source patient HBsAg status (if known)
  • Patient's susceptibility (vaccination history, anti-HBs levels)
  • Administration plan and dosing

Submission Portals & Electronic Systems

Primary Electronic Submission

  • CoverMyMeds: Most pharmacy prior authorizations
  • Availity Essentials: Check PA requirements and submit requests
  • eviCore Provider Portal: Complex medical benefit requests

Portal Access Requirements

  • Providers must register for each system
  • Upload supporting clinical documentation during submission
  • Track request status electronically
Note: Always verify the current portal requirements, as BCBSTX may update preferred submission methods.

Fax Numbers & Mailing Addresses

Appeals and Customer Service

  • Appeals Fax: 1-855-235-1055
  • Mailing Address: Blue Cross and Blue Shield of Texas
    Attn: Complaints and Appeals Department
    P.O. Box 660717
    Dallas, TX 75266-0717

Specialty Programs

  • STAR Kids Appeals: Same fax and address as above
  • FEP Expedited Appeals: 972-766-9776
  • Pharmacy Appeals Email: [email protected] (CHIP/Medicaid only)

Specialty Pharmacy Network

HyperHEP is typically managed under BCBSTX's specialty pharmacy program for provider administration:

In-Network Specialty Pharmacies

  • Accredo Pharmacy (primary preferred provider)
  • CHRISTUS Specialty Pharmacy (select medications)
  • Synergen RX (select medications)

Ordering Process

  1. Provider orders HyperHEP from Accredo or approved specialty pharmacy
  2. Medication delivered to provider's office for administration
  3. Provider bills only for administration, not the drug itself
  4. Prior authorization may be required before ordering
Important: Using out-of-network specialty pharmacies may result in coverage denial or higher out-of-pocket costs.

Support Phone Lines

Member Services

  • Customer Advocate: 1-888-657-6061 (TTY: 711)
    • Hours: Monday-Friday, 8 a.m. - 5 p.m. CT
    • Use for: Coverage questions, appeals, specialty drug inquiries

Plan-Specific Lines

  • STAR Kids Case Management: 1-877-688-1811 (TTY: 711)
  • TRS Personal Health Guide: 1-866-355-5999 (24/7)
  • FEP Prior Authorization: 1-800-441-9188

Pharmacy Support

  • Prime Therapeutics PA Hotline: 1-800-289-1525
  • eviCore Portal Support: 800-646-0418 (option 2)

Appeals Process

Internal Appeals Timeline

  • Commercial Plans: 180 days from denial to file appeal
  • CHIP/STAR/Medicaid: 60 days from denial
  • Decision Timeline: 30 calendar days for standard appeals

Required Appeal Documentation

  • Original denial letter
  • Medical necessity letter from provider
  • Clinical notes supporting HyperHEP need
  • Exposure documentation and timing
  • Patient's vaccination/antibody history

External Review (Texas)

If internal appeal is denied, Texas law provides independent external review through the Texas Department of Insurance:

  • Filing Deadline: 4 months from final internal denial
  • Review Timeline: 20 days standard, 5 days urgent
  • Cost: Paid by insurer
  • Decision: Binding on the insurer

Texas Regulatory Assistance

Texas Department of Insurance (TDI)

  • Consumer Hotline: 1-800-252-3439
  • Website: tdi.texas.gov
  • IRO Information Line: 1-866-554-4926

Office of Public Insurance Counsel (OPIC)

  • Help Line: 1-877-611-6742
  • Provides guidance on appealing denied claims
  • Free consumer assistance

Additional Resources

  • Disability Rights Texas: Assists with complex appeals
  • Texas Health and Human Services: For Medicaid fair hearings
From Our Advocates: "We've seen HyperHEP appeals succeed when providers document the exact exposure timing and include source patient testing results when available. The key is showing the urgency met CDC post-exposure guidelines—this composite experience reflects common success factors, though individual outcomes vary."

Coverage at a Glance

Requirement HealthSelect Commercial Plans Where to Verify
Prior Authorization Not required May be required Availity Portal
PCP Referral Required Varies by plan Member ID card
Timing Window 24 hours preferred 24 hours preferred Clinical Guidelines
Specialty Pharmacy Accredo preferred Accredo preferred Network List
Appeal Deadline 180 days 180 days Denial letter

FAQ

Q: How long does BCBS Texas take to approve HyperHEP? A: Emergency post-exposure requests are typically processed within 24-72 hours. Standard prior authorization reviews take up to 15 business days.

Q: What if my provider's office doesn't stock HyperHEP? A: BCBSTX requires ordering through in-network specialty pharmacies like Accredo, which deliver to your provider's office for administration.

Q: Can I get expedited approval for urgent exposure? A: Yes. Call the customer advocate line at 1-888-657-6061 and request expedited review for post-exposure prophylaxis.

Q: What happens if I'm denied coverage? A: You have 180 days to file an internal appeal, followed by independent external review through Texas Department of Insurance if needed.

Q: Does step therapy apply to HyperHEP? A: Generally no for true post-exposure prophylaxis, as timing is critical. However, verify with your specific plan.

Q: Are there patient assistance programs for HyperHEP? A: Contact Grifols patient support services or check with Counterforce Health for assistance with appeals and coverage options.

For patients and healthcare providers navigating complex insurance coverage decisions, Counterforce Health specializes in turning insurance denials into successful appeals by creating targeted, evidence-backed requests that align with each plan's specific requirements and medical policies.

When to Update This Information

BCBSTX updates prior authorization requirements quarterly, with major changes typically effective January 1st. Always verify current requirements through:

  • Availity Essentials portal for real-time PA status
  • BCBSTX provider communications for policy updates
  • Member ID card phone number for plan-specific questions

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by individual plan and are subject to change. Always consult with your healthcare provider and insurance plan directly for the most current requirements and coverage details.

Sources & Further Reading

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