By Counterforce Health Team in Ilaris (canakinumab) —

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

Answer Box: Fast Track to Approval

Getting Ilaris (canakinumab) covered by Blue Cross Blue Shield in Washington requires prior authorization with specific documentation. Here's the fastest path:

  1. Gather diagnostic evidence: Yamaguchi criteria for AOSD or ILAR criteria for SJIA, plus elevated inflammatory markers (ESR, CRP, ferritin >5x normal)
  2. Document prior therapies: Failed or contraindicated alternatives (NSAIDs, steroids, DMARDs)
  3. Submit comprehensive PA request: Include medical necessity letter, lab results, and treatment history through your provider portal

First step today: Contact your prescriber to begin gathering required documentation. Most Washington Blue Cross plans require 7-14 days for standard PA decisions, with expedited review available for urgent cases.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Mandatory for all Ilaris prescriptions Premera Blue Cross PA List
Formulary Status Specialty tier (highest cost-sharing) Member portal or benefits summary
Diagnosis Codes AOSD (M06.1) or SJIA (M08.2) required ICD-10 coding in medical records
Step Therapy May require trial of alternatives first Plan-specific PA criteria
Site of Care Preferred: office/infusion center vs. hospital Premera Site of Service Policy
Appeals Deadline 180 days from final internal denial Washington Insurance Code RCW 48.43.535

Step-by-Step: Fastest Path to Approval

1. Confirm Your Diagnosis Documentation

Who does it: Your rheumatologist or treating physician
What's needed: Clear documentation meeting established criteria:

  • AOSD: Yamaguchi criteria (≥5 total, ≥2 major criteria)
  • SJIA: ILAR criteria with fever pattern and systemic features

Timeline: Allow 1-2 visits for complete documentation

2. Gather Laboratory Evidence

Required tests:

  • Elevated ESR and CRP during active disease
  • Markedly elevated ferritin (often >5x upper limit)
  • Leukocytosis with neutrophil predominance
  • Negative ANA and rheumatoid factor

Pro tip: Low glycosylated ferritin (<20%) strengthens AOSD diagnosis

3. Document Prior Treatment History

Essential elements:

  • NSAIDs tried, dosages, duration, and response
  • Corticosteroid use and outcomes
  • Any DMARD trials (methotrexate, sulfasalazine)
  • Reasons for discontinuation (inefficacy, side effects, contraindications)

4. Submit Prior Authorization Request

Who submits: Your prescriber's office
How to submit: Through Blue Cross provider portal or designated PA forms
Include:

  • Completed PA form with diagnosis codes
  • Medical necessity letter (see checklist below)
  • Supporting lab results and imaging
  • Prior therapy documentation

Expected timeline: 7-14 business days for standard review

5. Monitor Decision and Prepare for Appeals

If approved: Coordinate with specialty pharmacy for delivery and administration If denied: Review denial letter carefully and begin appeal process immediately

Tip: Request expedited review if your condition is rapidly progressing or you're experiencing complications like macrophage activation syndrome.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
"Not medically necessary" Submit additional clinical evidence showing disease severity and failed alternatives
"Experimental/investigational" Reference FDA approval and published clinical guidelines
Step therapy not completed Document contraindications or previous failures to required medications
Insufficient documentation Provide complete medical records with clear diagnostic criteria
Off-label use Cite FDA labeling and peer-reviewed literature supporting the indication

Appeals Playbook for Washington

Internal Appeals (First Level)

Timeline: Must file within 180 days of denial
How to file: Written request to Blue Cross appeals department
Decision deadline: 30 days (72 hours if expedited)
Required documents:

  • Original denial letter
  • New supporting evidence
  • Physician appeal letter

External Review (Independent Review Organization)

When to use: After final internal appeal denial
How to request: Through your health plan or Washington Insurance Commissioner
Timeline: 30 days for standard review, 72 hours for expedited
Cost: Free to consumers
Decision: Binding on the insurer if overturned

Contact for help: Washington Insurance Commissioner Consumer Advocacy at 1-800-562-6900

Medical Necessity Letter Checklist

Your prescriber should include these elements:

Patient Information

  • Full name, DOB, insurance ID
  • Primary diagnosis with ICD-10 code
  • Disease duration and current severity

Clinical Rationale

  • Specific symptoms and functional limitations
  • Laboratory abnormalities (elevated inflammatory markers)
  • Risk of complications (MAS, joint destruction)

Treatment History

  • All prior medications tried, with specific names, doses, and durations
  • Reasons for discontinuation or inadequate response
  • Any contraindications to standard therapies

Ilaris-Specific Justification

  • FDA approval for your specific indication
  • Expected clinical benefits and monitoring plan
  • Dosing rationale based on weight and indication

Supporting Evidence

  • Reference to clinical guidelines
  • Peer-reviewed studies when applicable
  • FDA prescribing information

Costs & Savings Options

Manufacturer Support

  • Ilaris Co-pay Program: May reduce out-of-pocket costs for eligible patients
  • Patient Assistance Program: Income-based free drug program
  • Information: Ilaris Savings Support

Foundation Grants

  • Patient Advocate Foundation
  • HealthWell Foundation
  • National Organization for Rare Disorders (NORD)

State Resources

  • Washington Apple Health (Medicaid) may cover Ilaris with prior authorization
  • Prescription assistance through 211 Washington
Note: Specialty drug copays can be substantial even with insurance. Explore all assistance options before starting treatment.

When to Escalate

Contact Washington Insurance Commissioner if:

  • Your appeal is taking longer than required timelines
  • Blue Cross isn't following proper procedures
  • You need help understanding your rights

Washington Office of Insurance Commissioner
Consumer Advocacy: 1-800-562-6900
File a complaint online

Legal assistance: Consider consulting a healthcare attorney if facing repeated denials for a life-threatening condition.

Frequently Asked Questions

How long does Blue Cross Blue Shield prior authorization take in Washington? Standard PA requests: 7-14 business days. Expedited reviews (for urgent medical needs): 72 hours. Timelines start when complete documentation is received.

What if Ilaris isn't on my formulary? Request a formulary exception through your prescriber. Provide clinical justification why formulary alternatives aren't appropriate for your condition.

Can I get expedited review? Yes, if delay would seriously jeopardize your health. Your doctor must provide supporting documentation of urgency, such as rapidly progressing disease or risk of complications.

Does step therapy apply if I failed medications outside Washington? Yes, document all prior therapies regardless of where treatment occurred. Include complete records showing medication names, doses, durations, and reasons for discontinuation.

What's the success rate for Ilaris appeals in Washington? While specific statistics aren't publicly available, specialty drug appeals often succeed when supported by strong clinical evidence and proper documentation. Washington's external review process provides an additional layer of protection.

How much does Ilaris cost without insurance? Cash prices typically range from $20,000-$23,000 per 150mg syringe. Most patients receive multiple doses annually, making insurance coverage essential.

Can my doctor do a peer-to-peer review? Yes, most Blue Cross plans allow prescribers to request a peer-to-peer discussion with a plan medical director to discuss clinical rationale directly.

What if I have an employer self-funded plan? Self-funded employer plans may not be subject to Washington state insurance laws. However, many voluntarily follow similar appeal processes. Contact your HR department or plan administrator for specific procedures.

From Our Advocates

We've seen patients successfully overturn Ilaris denials by ensuring their rheumatologist documented not just the current disease severity, but also the specific reasons why each previously tried medication wasn't suitable—whether due to side effects, contraindications, or inadequate response. The key is painting a complete clinical picture that shows Ilaris as the logical next step, not just another option.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals through evidence-backed strategies. Our platform analyzes denial letters and plan policies to create targeted rebuttals that align with each insurer's specific requirements. By combining clinical expertise with payer-specific workflows, Counterforce Health streamlines the appeals process and improves approval rates for complex medications like Ilaris.

Whether you're navigating prior authorization requirements or preparing for an appeal, having the right documentation and strategy makes all the difference. The appeals process can feel overwhelming, but with proper preparation and persistence, many patients successfully obtain coverage for necessary medications. Don't hesitate to leverage resources like Counterforce Health and Washington's consumer advocacy services to strengthen your case.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and coverage requirements vary by plan and change frequently. Always verify current requirements with your specific Blue Cross Blue Shield plan and consult your healthcare provider for medical decisions. For personalized assistance with insurance appeals, contact the Washington Office of Insurance Commissioner or consider working with healthcare advocacy services.

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