By Counterforce Health Team in Imbruvica (ibrutinib) —

How to Get Imbruvica (ibrutinib) Covered by Blue Cross Blue Shield Florida: Complete Guide with Forms, Appeals, and Contact Numbers

Quick Answer: Getting Imbruvica Covered by Florida Blue

Florida Blue requires prior authorization for Imbruvica (ibrutinib) and typically requires step therapy with acalabrutinib (Calquence) or zanubrutinib (Brukinsa) first. Submit your PA request through the Availity portal with complete clinical documentation. If denied, you have 180 days to appeal internally, followed by external review through the Florida Department of Financial Services. Use Accredo (888-425-5970) or CVS Caremark Specialty (866-278-5108) for specialty pharmacy fulfillment.

Table of Contents

  1. Verify Your Plan and Find the Right Forms
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Upload Instructions
  4. Fax Numbers and Mailing Addresses
  5. Specialty Pharmacy Enrollment Process
  6. Support Phone Numbers and Case Management
  7. Florida Appeals and External Review Process
  8. When to Contact State Regulators

Verify Your Plan and Find the Right Forms

Before starting your Imbruvica prior authorization, confirm your specific Florida Blue plan type and formulary status:

Step 1: Check Your Coverage

  • Log into your Florida Blue member portal to access your current medication guide
  • Look for Imbruvica under "I" in the formulary - it's typically listed as requiring PA with step therapy
  • Note your plan type (ValueScript, NetResults, or CareChoices) as requirements may vary slightly

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required before dispensing Florida Blue PA Program
Step Therapy Must try acalabrutinib or zanubrutinib first ValueScript RX Guide
Specialty Pharmacy Must use Accredo or CVS Caremark Limited Distribution List
Appeals Deadline 180 days from denial notice Florida Blue Appeals Process

Prior Authorization Forms and Requirements

Required Documentation for Imbruvica PA:

Your oncologist must submit a comprehensive prior authorization request including:

  • Patient Information: Full name, date of birth, Florida Blue member ID, group number
  • Clinical Diagnosis: Specific indication (CLL/SLL, Waldenström's, cGVHD) with ICD-10 codes
  • Medical History: Complete treatment timeline showing prior therapies tried and failed
  • Laboratory Results: Recent CBC, comprehensive metabolic panel, and disease-specific markers
  • Prescriber Information: Oncologist's NPI, DEA number, and contact details
Clinician Corner: Medical Necessity Letter Checklist

Your letter should address: (1) Patient's specific diagnosis and staging, (2) Previous BTK inhibitor trials with acalabrutinib/zanubrutinib and reasons for discontinuation, (3) Contraindications to preferred agents, (4) Expected treatment duration and monitoring plan, (5) Citations to NCCN guidelines or FDA labeling supporting Imbruvica use.

Step Therapy Exception Requirements:

If requesting to bypass step therapy, document:

  • Allergy or intolerance to acalabrutinib or zanubrutinib
  • Previous trial and failure of preferred BTK inhibitors
  • Medical contraindications to step therapy drugs
  • Clinical urgency requiring immediate Imbruvica initiation

Submission Portals and Upload Instructions

Primary Submission Method: Availity Portal

Florida Blue requires all prior authorization requests to be submitted through Availity.com:

  1. Provider Registration: Your oncologist's office must have an active Availity account
  2. Navigate to PA Section: Select "Prior Authorization" from the main menu
  3. Select Florida Blue: Choose your specific plan type from the insurer list
  4. Upload Requirements: Attach all clinical documentation, lab results, and medical necessity letter
  5. Confirmation: Save your submission confirmation number for tracking

Alternative: CoverMyMeds Integration

Some providers may use CoverMyMeds which integrates with Florida Blue's system:

  • Phone support: 866-452-5017
  • Electronic submission reduces processing time to 24-48 hours

Fax Numbers and Mailing Addresses

Florida Blue Contact Numbers for Imbruvica PA:

Purpose Phone Fax
Prior Authorization 800-955-5692 888-656-6671
Case Management 866-287-9569 -
Provider Portal Support 800-282-4548 -
Medicare Advantage 954-714-4109 (fax) 954-714-4109

Fax Cover Sheet Tips:

  • Include "URGENT - IMBRUVICA PRIOR AUTHORIZATION" in subject line
  • List member ID, group number, and prescriber NPI prominently
  • Number all pages and include total page count
  • Request fax confirmation receipt

Specialty Pharmacy Enrollment Process

Imbruvica is a limited distribution drug requiring enrollment with Florida Blue's contracted specialty pharmacies.

In-Network Specialty Pharmacies:

Accredo Specialty Pharmacy

  • Phone: 888-425-5970
  • Fax: 888-302-1028
  • Available 24/7 for urgent cases

CVS Caremark Specialty Pharmacy

  • Phone: 866-278-5108
  • Fax: 800-323-2445
  • Online portal available for prescription tracking

Enrollment Steps:

  1. Initial Contact: Call your chosen specialty pharmacy with your Florida Blue member ID
  2. Benefits Verification: Pharmacy will verify coverage and copay requirements
  3. Prescription Transfer: If transferring from another pharmacy, provide current prescription details
  4. Delivery Setup: Arrange home delivery or pickup preferences
  5. Monitoring Services: Enroll in adherence monitoring and side effect tracking programs

Counterforce Health can help coordinate the specialty pharmacy enrollment process and ensure all required documentation is properly submitted to avoid delays in therapy initiation.

Support Phone Numbers and Case Management

Member Support Lines:

  • General Member Services: 877-719-2583
  • Pharmacy Benefits: 800-955-5692
  • Case Management: 866-287-9569 (for complex cases requiring care coordination)

What to Ask When Calling:

  • Current PA status and expected decision timeline
  • Specific denial reasons if your request was rejected
  • Required documentation for resubmission
  • Expedited review options for urgent cases
  • Step therapy exception process

Provider Support:

  • Availity Technical Support: 800-282-4548
  • Provider Customer Service: 800-727-2227

Florida Appeals and External Review Process

Internal Appeals Process

Timeline: 180 days from denial notice to file internal appeal

Required Documentation:

  • Original denial letter from Florida Blue
  • Complete medical records supporting medical necessity
  • Updated letter from prescribing oncologist
  • Any new clinical information since original request

Submission Methods:

  • Online through Florida Blue member portal
  • Fax: Use the same prior authorization fax numbers listed above
  • Mail: Address provided in your denial letter

Review Timeline:

  • Standard review: 30 days
  • Expedited review: 72 hours (for urgent cases)

Peer-to-Peer Review

Before formal appeal, request a peer-to-peer review where your oncologist speaks directly with Florida Blue's medical director:

  • Call 877-719-2583 to schedule
  • Usually scheduled within 72 hours
  • 15-30 minute discussion focusing on medical necessity
  • Can often resolve denials without formal appeal

External Review Through Florida DFS

If your internal appeal is denied, you can request external review through the Florida Department of Financial Services:

Timeline: 4 months from final internal denial Cost: Free to consumers Contact: Florida Department of Financial Services

  • Phone: 877-693-5236
  • Online complaint portal available

Required Documentation:

  • Final internal appeal denial letter
  • All medical records and supporting documentation
  • Completed external review request form
  • Statement explaining why treatment is medically necessary
From Our Advocates

In our experience helping patients navigate Florida Blue denials, the most successful appeals include a detailed timeline of all previous BTK inhibitor trials, specific adverse events that led to discontinuation, and clear citations to NCCN guidelines. We've seen cases where initial denials were overturned within 48 hours when the clinical picture was presented comprehensively.

When to Contact State Regulators

Contact Florida's Insurance Consumer Helpline if:

  • Florida Blue fails to respond within required timelines
  • You're having difficulty accessing the appeals process
  • You believe the denial violates Florida insurance law

Florida Department of Financial Services Consumer Helpline:

  • Phone: 877-693-5236
  • Website: MyFloridaCFO.com
  • Email complaints accepted through online portal

When Filing a Complaint, Include:

  • Your Florida Blue member ID and group number
  • Timeline of all communications with Florida Blue
  • Copies of denial letters and appeal submissions
  • Medical records supporting necessity of Imbruvica

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn Documentation Needed
Step therapy not completed Document trials of acalabrutinib/zanubrutinib Pharmacy records, adverse event documentation
Insufficient clinical information Submit comprehensive medical records Complete treatment history, lab results, imaging
Off-label use not supported Provide guideline citations NCCN guidelines, FDA labeling, peer-reviewed studies
Quantity limits exceeded Justify higher dose requirements Weight-based dosing calculations, body surface area

Costs and Financial Assistance

Manufacturer Support:

  • Imbruvica By Your Side program offers copay assistance up to $25,000 annually for eligible patients
  • Income-based assistance available for uninsured patients

Florida-Specific Resources:

  • Florida Blue's own financial hardship programs
  • Cancer support organizations with prescription assistance
  • Clinical trial options through Florida cancer centers

Frequently Asked Questions

How long does Florida Blue PA approval take? Standard review is 72 hours for electronic submissions, up to 14 days for fax submissions. Expedited reviews are completed within 24 hours for urgent cases.

What if Imbruvica isn't on my formulary? Submit a formulary exception request with your PA, demonstrating medical necessity and lack of suitable alternatives on formulary.

Can I get expedited approval? Yes, if your oncologist certifies that delay could seriously jeopardize your health. Call 877-719-2583 to request expedited review.

Does step therapy apply if I failed BTK inhibitors outside Florida? Previous trials with other insurers should count toward step therapy requirements. Include all pharmacy records and clinical notes from previous treatments.

What if I'm switching from another Blue Cross plan? Coverage criteria may vary between Blue plans. Submit a new PA request with complete clinical history, even if previously approved.

Update Frequency and Resource Maintenance

Florida Blue updates their formulary and prior authorization requirements annually, typically effective January 1st. Check for updates:

  • Quarterly: Review your plan's medication guide for formulary changes
  • Annually: Verify specialty pharmacy network participation
  • Before refills: Confirm continued coverage, especially if changing from brand to generic formulations

Counterforce Health helps patients and clinicians stay current with changing insurance requirements and can provide updated appeal templates when policies change.

Disclaimer: This information is for educational purposes only and is not medical advice. Coverage decisions depend on your specific plan and clinical circumstances. Always consult with your healthcare provider and insurance plan directly for the most current requirements and procedures.

Sources and Further Reading

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