By Counterforce Health Team in Kalydeco (ivacaftor) —

How to Get Kalydeco (ivacaftor) Covered by Horizon Blue Cross Blue Shield New Jersey: Complete Guide to Prior Authorization and Appeals

Answer Box: Getting Kalydeco Covered in New Jersey

Horizon Blue Cross Blue Shield of New Jersey requires prior authorization for Kalydeco (ivacaftor). The fastest path to approval: 1) Confirm your CFTR mutation testing shows an FDA-approved responsive mutation, 2) Have your CF specialist submit the PA request through Horizon's provider portal with complete genetic documentation, and 3) If denied, use New Jersey's Independent Health Care Appeals Program (IHCAP) for external review. Start today by calling Horizon Pharmacy Member Services at 1-800-370-5088 to verify your specific plan's requirements.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Kalydeco prescriptions Horizon BCBSNJ PA Search Tool
CFTR Mutation Testing Must document FDA-approved responsive mutation FDA labeling, genetic test report
Specialty Pharmacy Must use in-network specialty pharmacy Horizon Specialty Pharmacy List
30-Day Supply Limit Typically dispensed monthly Plan formulary documents
Age Requirements Per FDA labeling (varies by mutation) FDA prescribing information

Step-by-Step: Fastest Path to Approval

1. Verify Your Coverage and Plan Type

Who does it: You or your caregiver
What you need: Insurance card, member ID
Action: Call Horizon member services at 1-800-370-5088 or log into your member portal to confirm Kalydeco is on your formulary and what prior authorization requirements apply to your specific plan.
Timeline: 10-15 minutes

2. Confirm CFTR Mutation Testing

Who does it: Your CF care team
What you need: Genetic test results showing specific CFTR mutations
Action: Ensure your genetic testing documents an FDA-approved mutation responsive to ivacaftor (such as G551D, R117H, or other gating mutations). If testing is incomplete, request comprehensive CFTR gene sequencing.
Timeline: Results typically available within 1-2 weeks if new testing is needed

3. Gather Required Documentation

Who does it: Your CF specialist and care team
What you need:

  • Complete CFTR genetic test results
  • CF diagnosis with ICD-10 codes
  • Documentation of prior therapies (if applicable)
  • Current clinical notes and lab results Timeline: 2-3 business days to compile

4. Submit Prior Authorization Request

Who does it: Your prescribing physician
What you need: Completed PA form and supporting documentation
Action: Provider submits through Horizon's provider portal via Availity Essentials with all required clinical documentation.
Timeline: 5-7 business days for routine requests, 24-48 hours for urgent requests

5. Set Up Specialty Pharmacy

Who does it: You and your care team
What you need: Approved PA and prescription
Action: Transfer prescription to an approved Horizon specialty pharmacy. Contact the pharmacy to coordinate delivery and refill schedules.
Timeline: 2-3 business days for initial setup

6. If Denied: File Internal Appeal

Who does it: You or your provider
What you need: Denial letter, additional clinical documentation
Action: Submit appeal through Horizon's member portal or provider portal within the timeframe specified in your denial letter.
Timeline: Horizon must respond within specified timeframes per your plan documents

7. If Still Denied: File External Review

Who does it: You or your provider (with consent)
What you need: Final denial letter from Horizon
Action: Submit external appeal to New Jersey IHCAP via Maximus within 60 days of final internal denial.
Timeline: Decision typically within 45 days

Forms and Submission Portals

For Providers

  • Primary submission method: Horizon Provider Portal via Availity Essentials
  • Support: Provider services line for technical assistance
  • Required information: Patient demographics, diagnosis codes, genetic testing results, clinical justification

For Members

  • Member portal: Access through HorizonBlue.com member login
  • Phone support: 1-800-370-5088 for Horizon Pharmacy Member Services
  • Appeals submissions: Can be submitted through member portal or by mail/fax as directed in denial letters
Tip: Always use electronic submission when possible. It provides tracking capabilities and faster processing times compared to fax or mail submissions.

Common Denial Reasons & Solutions

Denial Reason How to Address It
Missing CFTR mutation documentation Submit comprehensive genetic testing results showing specific responsive mutations
Age requirements not met Provide documentation that patient meets FDA labeling age criteria for their specific mutation
Lack of specialist confirmation Ensure prescription comes from CF specialist or pulmonologist with CF expertise
Insufficient prior therapy documentation Document previous treatments tried, failed, or contraindicated (if applicable per FDA labeling)
Quantity limits exceeded Request exception with clinical justification for prescribed quantity

Appeals Process for New Jersey

Internal Appeals with Horizon BCBS

  1. First Level: Submit within timeframe specified in denial letter (typically 60 days)
  2. Second Level: If first appeal denied, submit second-level appeal
  3. Expedited appeals: Available if delay would seriously jeopardize health

External Review Through New Jersey IHCAP

After completing Horizon's internal appeal process, you can request external review through New Jersey's Independent Health Care Appeals Program.

Contact Information:

Key Requirements:

  • Must file within 60 days of final internal denial
  • Only available for fully insured plans (not self-funded employer plans)
  • No cost to you—insurer pays all review costs
  • Decision is binding on the insurance company

Cost Savings and Patient Support

Vertex Patient Support Programs

Vertex Pharmaceuticals offers several programs to help with Kalydeco costs:

  • Vertex Compass: Patient support program providing insurance navigation and financial assistance information
  • Copay assistance: For eligible commercially insured patients

Foundation Support

Several organizations provide grants for CF medications:

  • Cystic Fibrosis Foundation: Compass program for financial assistance
  • Patient Access Network (PAN) Foundation: Grants for CF treatments
  • Good Days: Chronic disease financial assistance
Note: Eligibility requirements vary by program. Contact each organization directly to determine if you qualify.

Frequently Asked Questions

Q: How long does Horizon BCBS prior authorization take in New Jersey?
A: Routine requests: 5-7 business days. Urgent requests: 24-48 hours. Timeline starts when Horizon receives complete documentation.

Q: What if Kalydeco isn't on my Horizon formulary?
A: You can request a formulary exception. Your doctor must provide clinical justification for why Kalydeco is medically necessary and other formulary options are inappropriate.

Q: Can I get an expedited appeal if I'm already taking Kalydeco?
A: Yes, if stopping or delaying Kalydeco would seriously jeopardize your health. Your doctor must provide documentation supporting the urgent medical need.

Q: Does step therapy apply to Kalydeco?
A: Step therapy requirements vary by plan. Since Kalydeco targets specific CFTR mutations, step therapy may not apply if you have a documented responsive mutation and meet FDA labeling criteria.

Q: What happens if I move from New Jersey to another state?
A: Appeal rights and external review processes vary by state. Contact your new state's insurance department for local appeal procedures.

Q: Can my CF care team help with the appeals process?
A: Yes, many CF centers have social workers or patient navigators experienced with insurance appeals. Ask your care team about available support services.

When to Contact New Jersey Regulators

Contact the New Jersey Department of Banking and Insurance if:

  • Horizon doesn't follow proper appeal procedures
  • You experience unreasonable delays in processing
  • You need help understanding your appeal rights

Contact Information:

  • Consumer Hotline: 1-800-446-7467
  • IHCAP-specific questions: 1-888-393-1062
  • Email: [email protected]

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. The platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that address specific denial reasons with the right clinical documentation and regulatory citations.

This guide is for informational purposes only and does not constitute medical or legal advice. Coverage policies and procedures may change. Always verify current requirements with your insurance plan and consult with your healthcare team for medical decisions. For the most up-to-date appeal procedures and forms, visit the official Horizon BCBS New Jersey website and New Jersey Department of Banking and Insurance.

Sources & Further Reading

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