By Counterforce Health Team in Juxtapid (lomitapide) —

How to Get Juxtapid (lomitapide) Covered by Blue Shield of California: Forms, Appeals, and Authorization Guide 2025

Answer Box: Getting Juxtapid Covered by Blue Shield of California

Juxtapid (lomitapide) requires prior authorization from Blue Shield of California for homozygous familial hypercholesterolemia (HoFH). The fastest path: (1) Confirm genetic/clinical HoFH diagnosis with LDL-C ≥400 mg/dL or total cholesterol >500 mg/dL, (2) Document failed trials of standard lipid-lowering therapies, and (3) Submit PA request through AuthAccel portal with complete clinical documentation. If denied, California residents have strong appeal rights through Independent Medical Review (IMR) with an 89% success rate for overturning inappropriate denials.

Table of Contents

  1. Start Here: Verify Your Plan and Find Forms
  2. Required Forms for Prior Authorization
  3. Submission Portals and Online Systems
  4. Fax and Mail Submission Details
  5. Specialty Pharmacy Network Requirements
  6. Support Lines and Contact Numbers
  7. California Appeal Rights and IMR Process
  8. Common Denial Reasons and How to Fix Them
  9. Medical Necessity Documentation Checklist
  10. FAQ: Juxtapid Coverage Questions

Start Here: Verify Your Plan and Find Forms

Blue Shield of California operates different product lines with varying formulary requirements. First, confirm your specific plan type by checking your member ID card or calling the customer service number listed on your card.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before dispensing PA List Blue Shield CA
Genetic Testing HoFH confirmation needed Clinical notes or genetic report FDA Label
Step Therapy Must try other agents first Plan formulary Blue Shield CA
Specialty Pharmacy CVS Specialty required Specialty Program Blue Shield CA
Appeals Deadline 65 days for Medicare; varies commercial Member handbook Blue Shield CA

Check your formulary status: Juxtapid may be listed as non-formulary or require special authorization. Access your plan's drug formulary through the Blue Shield member portal to confirm current status.

Required Forms for Prior Authorization

Primary Authorization Form

Submit pharmacy prior authorization requests using the Prescription Drug Prior Authorization form available through Blue Shield's authorization forms page. The form requires:

  • Complete patient demographics and insurance information
  • Prescriber details and NPI number
  • Detailed diagnosis with ICD-10 codes (E78.01 for HoFH)
  • Medication strength, quantity, and directions
  • Clinical justification and supporting documentation

Non-Formulary Exception Request

If Juxtapid is not on your plan's formulary, use the Non-formulary Exception and Quantity Limit Exception form available in the member forms section. Your physician must provide a statement explaining why formulary alternatives would be ineffective or cause adverse effects.

Tip: Download the most current form versions, as Blue Shield updates requirements periodically. Outdated forms may cause processing delays.

Submission Portals and Online Systems

AuthAccel Online System

Providers can submit and track authorization requests through AuthAccel, Blue Shield's online authorization platform. Benefits include:

  • Real-time auto-approval for eligible requests
  • Status tracking regardless of submission method
  • Electronic Prior Authorization Questionnaire for additional clinical information
  • Integration with Surescripts® and CoverMyMeds® EHR platforms

Electronic Prior Authorization (ePA)

Providers using compatible EHR systems can submit requests electronically for real-time response at point of care. This method provides the fastest determination for straightforward cases.

Fax and Mail Submission Details

Fax Submission

Primary fax number: (888) 697-8122

Include a cover sheet with:

  • Patient name and member ID
  • Prescriber name and contact information
  • "URGENT - Specialty Medication Prior Authorization" notation
  • Total number of pages being transmitted

Mail Submission

Address for pharmacy authorizations: Blue Shield of California
Attn: Pharmacy Authorization
3300 Zinfandel Drive
Rancho Cordova, CA 95670

Allow 5-7 business days for mail processing versus 2-3 days for fax or online submission.

Specialty Pharmacy Network Requirements

CVS Specialty Network

Once prior authorization is approved, prescriptions must be filled through CVS Specialty®:

CVS Specialty Contact:

  • Phone: (800) 237-2767
  • Fax: (800) 323-2445

Medication Drop Ship Program

California providers in commercial PPO plans can use Blue Shield's Medication Drop Ship Program, where the physician's office orders directly from network specialty pharmacies. The pharmacy delivers to your office and bills Blue Shield directly, while you bill only administration fees.

Support Lines and Contact Numbers

Patient Support Lines

  • General pharmacy questions: Customer service number on member ID card
  • Specialty drug program: (888) 346-3731 (TTY: (877) 853-9549)
  • Prior authorization status: (800) 535-9481

Provider Support

  • Authorization questions: (800) 535-9481
  • Formulary information: Same number as above
  • Technical portal support: Available through AuthAccel system
Note: Have your member ID, group number, and prescription details ready when calling to expedite assistance.

California Appeal Rights and IMR Process

California provides exceptionally strong appeal rights through the Department of Managed Health Care (DMHC) Independent Medical Review system.

Step-by-Step Appeals Process

  1. File Internal Appeal: Submit written appeal within 65 days of denial notice
  2. Wait for Decision: Blue Shield has 30 days for standard appeals, 72 hours for expedited
  3. Request IMR: If denied, file Independent Medical Review within 6 months
  4. IMR Decision: Independent physicians review within 45 days (7 days expedited)
  5. Binding Result: Blue Shield must comply with IMR determination

IMR Contact Information

DMHC Help Center: (888) 466-2219
Online IMR application: healthhelp.ca.gov

Success rates: California IMR physicians uphold approximately 89% of appropriate treatment requests, making this an effective avenue for medically necessary specialty medications.

Common Denial Reasons and How to Fix Them

Denial Reason Documentation Needed How to Fix
Missing HoFH diagnosis Genetic testing or clinical criteria Submit genetic report showing LDLR/APOB/PCSK9 mutations OR clinical documentation of untreated LDL-C ≥400 mg/dL
Step therapy not completed Prior medication trials Document failed trials of statins, ezetimibe, PCSK9 inhibitors with specific reasons (ineffective, intolerant, contraindicated)
Liver monitoring plan absent Hepatic safety protocol Submit detailed monitoring schedule per FDA REMS requirements
Drug interactions Medication reconciliation Review and discontinue strong CYP3A inhibitors; provide updated medication list

Medical Necessity Documentation Checklist

Clinical Documentation Requirements

Essential elements for approval:

✓ Confirmed HoFH diagnosis with genetic testing results or clinical criteria
✓ Baseline LDL-C levels (untreated and on maximum tolerated therapy)
✓ Prior therapy documentation including specific medications tried, doses, duration, and reasons for discontinuation
✓ Liver function monitoring plan per FDA REMS requirements
✓ Contraindication screening for strong CYP3A inhibitors
✓ Treatment goals and expected LDL-C reduction targets

Supporting Evidence

Include peer-reviewed literature supporting lomitapide use in HoFH, such as:

  • FDA prescribing information demonstrating efficacy
  • Clinical trial data for HoFH population
  • Professional society guidelines (National Lipid Association, American Heart Association)

Counterforce Health specializes in turning insurance denials into successful appeals by identifying the specific denial basis and crafting evidence-backed rebuttals aligned to each plan's own coverage rules. Their platform helps patients and providers navigate complex prior authorization requirements with payer-specific workflows and compliance documentation.

FAQ: Juxtapid Coverage Questions

How long does Blue Shield of California prior authorization take?
Standard requests: 5-7 business days. Expedited requests (urgent medical need): 24-72 hours. Electronic submissions through AuthAccel may receive real-time approval for straightforward cases.

What if Juxtapid is non-formulary on my plan?
Submit a formulary exception request with clinical justification. Your physician must demonstrate that formulary alternatives would be less effective or cause adverse effects for your specific condition.

Can I request expedited review if my condition is urgent?
Yes. Contact Blue Shield immediately at the number on your member card to request expedited prior authorization or appeal if you have urgent clinical need.

Does step therapy apply if I've tried medications outside California?
Yes, but document all prior therapies regardless of where they were prescribed. Include medical records showing specific medications, doses, duration, and reasons for discontinuation.

What are my rights if Blue Shield denies coverage?
California residents can file an Independent Medical Review through DMHC. This independent physician review is binding on Blue Shield and has strong success rates for medically appropriate treatments.

How much does Juxtapid cost without insurance?
Juxtapid typically costs in the mid-five figures per 28-day supply. Patient assistance programs through the manufacturer may help eligible patients access the medication.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Coverage policies change frequently; verify current requirements with Blue Shield of California and consult your healthcare provider for medical decisions. For personalized assistance with complex authorization challenges, Counterforce Health provides specialized support in navigating insurance appeals and prior authorization requirements.

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