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

How to Get HyperHEP (Hepatitis B Immune Globulin) Covered by Blue Cross Blue Shield in Washington: Complete PA Guide with Forms and Appeals

Answer Box: Getting HyperHEP Covered in Washington

Blue Cross Blue Shield plans in Washington require prior authorization for HyperHEP (hepatitis B immune globulin). To get approved: 1) Have your provider submit a PA request through Availity Essentials with exposure documentation and CDC guideline references, 2) Include timing (within 7 days of exposure), vaccination status, and medical necessity, 3) Request expedited review for urgent cases. If denied, you have 180 days to appeal internally, then can request external review through Washington's Office of Insurance Commissioner. Success rates improve significantly with complete documentation and CDC guideline citations.

Table of Contents

Plan Types & Coverage Implications

Blue Cross Blue Shield operates through multiple companies in Washington, primarily Premera Blue Cross and Regence BlueShield. Your specific plan type affects how HyperHEP coverage works:

Commercial Plans (Individual/Group):

  • HMO plans may require referrals for specialist administration
  • PPO plans offer more flexibility in provider choice
  • All plans require prior authorization for HyperHEP

Medicare Advantage:

  • Subject to CMS guidelines for hepatitis B immune globulin
  • May have different formulary placement than commercial plans

Apple Health (Medicaid):

  • Managed through contracted plans like Molina or Coordinated Care
  • Often has streamlined approval for post-exposure prophylaxis
Note: If you're unsure which Blue Cross Blue Shield company covers you, check your member ID card or call the member services number listed.

Formulary Status & Tier Placement

HyperHEP is typically covered under the medical benefit rather than pharmacy benefit for Blue Cross Blue Shield Washington plans. This means:

  • Not subject to traditional formulary tiers (Tier 1, 2, 3)
  • Covered when medically necessary for approved indications
  • No step therapy requirements for urgent post-exposure use
  • Alternative products include other hepatitis B immune globulin brands

The key factor isn't formulary tier but meeting medical necessity criteria based on CDC post-exposure prophylaxis guidelines.

Prior Authorization Requirements

Coverage Requirements Table

Requirement What It Means Documentation Needed Source
Exposure Documentation Proof of hepatitis B exposure risk Date, time, nature of exposure CDC Guidelines
Timing Window Administration within 7 days Medical records showing exposure date Premera Policy
Vaccination Status Patient's HBV immunity status Vaccination records, serology if available CDC ACIP Recommendations
Medical Necessity Clinical justification for HBIG Provider attestation, guideline references Plan-specific criteria

Required Documentation

Your healthcare provider must submit:

  1. Exposure details: Date, time, source, and nature of contact
  2. Patient immunity status: Vaccination history and anti-HBs levels if known
  3. Clinical rationale: Why HBIG is medically necessary
  4. Timing justification: Confirmation administration is within CDC-recommended window
  5. Billing codes: HCPCS 90371 with appropriate ICD-10 codes

Specialty Pharmacy Network

While HyperHEP is administered in clinical settings, Blue Cross Blue Shield Washington works with specialty pharmacy partners for coordination:

Premera Blue Cross Specialty Partners:

  • Accredo Specialty Pharmacy
  • AllianceRx Walgreens Prime
  • Local specialty pharmacies (verify network status)

Regence BlueShield:

  • Uses contracted specialty pharmacy network
  • Verify specific partners through member portal
Tip: For urgent post-exposure needs, hospital pharmacies and urgent care centers can typically provide HyperHEP immediately while PA is processed.

Cost-Share Basics

Your out-of-pocket costs depend on your specific plan design:

Typical Cost Structure:

  • Deductible: May apply if not met for the year
  • Coinsurance: Usually 10-30% after deductible
  • Copay: Some plans have flat copays for specialty medications
  • Out-of-pocket maximum: Protects from excessive costs

Cost-Saving Options:

  • Manufacturer copay assistance (check eligibility)
  • Hospital charity care programs
  • Washington state pharmaceutical assistance programs

Step-by-Step: Fastest Path to Approval

1. Immediate Assessment (Provider)

Who: Healthcare provider Action: Document exposure details and assess urgency Timeline: Immediately after exposure identified Forms: Clinical assessment notes

2. Gather Documentation (Clinic Staff)

Who: Medical assistant or nurse Action: Collect vaccination records, lab results, exposure timeline Timeline: Within 2-4 hours of assessment Documents: Vaccination card, serology results, incident report

3. Submit Prior Authorization (Provider)

Who: Provider or designated staff Action: Complete PA request through Availity Essentials Timeline: Within 6-12 hours of exposure Portal: Electronic submission preferred for fastest processing

4. Request Expedited Review (If Urgent)

Who: Provider Action: Mark as urgent/expedited due to post-exposure timing Timeline: Same day as PA submission Justification: Reference 24-48 hour optimal treatment window

5. Follow Up (Clinic)

Who: Prior authorization coordinator Action: Monitor portal for status updates Timeline: Check within 24 hours, then daily Response: Provide additional information if requested

6. Administer Treatment (Provider)

Who: Healthcare provider Action: Administer HyperHEP once approved Timeline: As soon as possible after approval Documentation: Record administration details for billing

7. Submit Claims (Billing)

Who: Medical billing staff Action: Submit claims with proper codes and documentation Timeline: Within 30 days of administration Codes: HCPCS 90371, appropriate ICD-10

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Required Documentation
Outside timing window Provide detailed exposure timeline Medical records showing actual exposure date
Insufficient medical necessity Submit comprehensive clinical justification CDC guidelines, provider attestation
Missing vaccination history Document immunity status or inability to determine Vaccination records or serology results
Incorrect coding Resubmit with proper HCPCS/ICD-10 codes Billing correction with clinical support
Provider network issues Verify in-network status or request exception Network verification, medical necessity for specific provider

Appeals Process in Washington

Washington state provides robust protections for insurance denials through a structured appeals process.

Internal Appeals (First Level)

Timeline: Must file within 180 days of denial Decision Time: 30 days standard, 72 hours for urgent cases How to File: Through member portal, written request, or phone Required Documents:

  • Denial letter
  • Medical records supporting necessity
  • Provider letter referencing CDC guidelines
  • Any additional clinical documentation

External Review (Independent Review Organization)

If your internal appeal is denied, Washington law provides access to binding external review through the Office of Insurance Commissioner.

Process:

  1. File Request: Submit to OIC within 4 months of final internal denial
  2. Assignment: OIC assigns certified Independent Review Organization (IRO)
  3. Review: Medical specialists review case based on clinical evidence
  4. Decision: Binding determination within 15 days (72 hours if urgent)
  5. Cost: Free to patient

Success Factors:

  • Complete medical documentation
  • Clear reference to CDC post-exposure prophylaxis guidelines
  • Detailed exposure timeline and risk assessment
  • Provider support letter
From our advocates: We've seen Washington patients successfully overturn HyperHEP denials by emphasizing the time-sensitive nature of post-exposure prophylaxis and providing comprehensive CDC guideline documentation. The key is demonstrating that the exposure occurred within the recommended treatment window and that the patient lacks adequate immunity.

Clinician Corner: Medical Necessity Letters

Essential Elements for Approval

Patient Information:

  • Demographics and insurance details
  • Relevant medical history
  • Current hepatitis B vaccination status

Exposure Details:

  • Date, time, and circumstances of exposure
  • Source patient HBsAg status (if known)
  • Type of exposure (percutaneous, mucosal, sexual)

Clinical Rationale:

Treatment Plan:

  • HyperHEP dosing (0.06 mL/kg IM)
  • Concurrent hepatitis B vaccination plan
  • Follow-up serology timeline

Counterforce Health can help healthcare providers and patients navigate the complex prior authorization process for HyperHEP and other specialty medications. Our platform analyzes denial patterns and creates targeted, evidence-based appeals that align with payer-specific requirements, potentially saving weeks in the approval process.

FAQ

How long does Blue Cross Blue Shield PA take in Washington? Standard reviews take 3-5 business days, while urgent post-exposure cases can be approved within 24-72 hours if marked as expedited.

What if HyperHEP is denied initially? You have 180 days to file an internal appeal with additional documentation. If that fails, Washington's external review process provides binding independent review.

Does step therapy apply to HyperHEP? No, step therapy requirements don't apply to urgent post-exposure prophylaxis situations where timing is critical.

Can I get HyperHEP at any pharmacy? HyperHEP is typically administered in clinical settings (hospitals, urgent care, physician offices) rather than dispensed from retail pharmacies.

What codes should my provider use? HCPCS code 90371 for HyperHEP administration, plus appropriate ICD-10 codes for the exposure type (Z87.891 for personal history of nicotine dependence, Z20.5 for contact with hepatitis).

Is there financial assistance available? Check with Grifols (manufacturer) for patient assistance programs, and ask about hospital charity care if receiving treatment in an emergency setting.

What if my plan is self-funded (ERISA)? Self-funded employer plans may not be subject to Washington state external review laws, but many voluntarily participate. Contact the U.S. Department of Labor for ERISA-specific appeal rights.

How do I know which Blue Cross Blue Shield company I have? Check your member ID card - it will specify Premera Blue Cross, Regence BlueShield, or another Blue plan. Each has slightly different processes but similar coverage criteria.

Sources & Further Reading

For personalized assistance with HyperHEP prior authorization and appeals, Counterforce Health provides specialized support in turning insurance denials into successful approvals through evidence-based appeal strategies.

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 specific coverage details. Coverage policies may vary by plan and are subject to change.

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