By Counterforce Health Team in Kineret (anakinra) —

How to Get Kineret (anakinra) Covered by Blue Cross Blue Shield in Washington: Complete Prior Authorization Guide

Answer Box: Getting Kineret Covered by Blue Cross Blue Shield in Washington

Blue Cross Blue Shield plans in Washington (Premera Blue Cross and Regence BlueShield) require prior authorization for Kineret (anakinra). Success depends on documenting failed conventional DMARDs for rheumatoid arthritis or confirmed NOMID diagnosis. If denied, Washington's external review process through an Independent Review Organization (IRO) has strong patient protections.

First steps today:

  1. Identify your exact plan (Premera vs. Regence)
  2. Download the plan-specific prior authorization form
  3. Gather documentation of failed DMARD trials and infection screening

Timeline: PA decisions typically within 7-14 days; appeals must be filed within 60 days; external review available within 72 hours for urgent cases.

Table of Contents

Understanding Blue Cross Blue Shield Coverage in Washington

Washington state has two main Blue Cross Blue Shield carriers, each with different formularies and prior authorization processes:

Premera Blue Cross

  • Covers commercial, individual, and Medicare Advantage plans
  • Kineret listed on 2024 formulary with prior authorization required
  • Uses step therapy for some specialty biologics

Regence BlueShield

  • Primarily commercial and individual plans
  • Treats Kineret as specialty drug requiring medical necessity review
  • May require preferred biologic trials first
Tip: Check your member ID card to confirm which carrier you have. The prior authorization forms and criteria differ between Premera and Regence.

Reading Your Denial Letter

Your denial letter contains critical information for your appeal:

Key elements to identify:

  • Denial reason code (step therapy, non-formulary, medical necessity)
  • Appeal deadline (typically 60-180 days from denial date)
  • Required documentation for reconsideration
  • Expedited appeal option if medically urgent

Common denial reasons for Kineret:

  • Failure to try required conventional DMARDs
  • Missing infection screening documentation
  • Concurrent biologic therapy
  • Off-label use without compendia support

Prior Authorization Requirements

Coverage at a Glance

Requirement Premera Blue Cross Regence BlueShield Documentation Needed
PA Required Yes Yes Completed PA form
Formulary Tier Specialty Specialty Check plan-specific formulary
Step Therapy Likely for RA Varies by plan Failed DMARD documentation
Quantity Limits 1 syringe/day 1 syringe/day Dosing justification
Age Limits ≥18 for RA ≥18 for RA Date of birth verification

Medical Necessity Criteria

Based on national Blue Cross Blue Shield policies and Washington plan patterns:

For Rheumatoid Arthritis:

  • Age 18 or older
  • Moderate to severe active RA diagnosis
  • Failed or intolerant to at least one conventional DMARD (typically methotrexate)
  • No active serious infections
  • Not used with other biologics or JAK inhibitors

For NOMID/CAPS:

  • Confirmed genetic or clinical diagnosis
  • Dosing not exceeding 8 mg/kg/day
  • Specialist consultation required

Building Your Medical Necessity Case

Clinician Corner: Medical Necessity Letter Checklist

Your prescriber's letter should include:

Clinical Documentation:

  • Specific RA or NOMID diagnosis with ICD-10 code
  • Disease activity measures and severity markers
  • Functional impairment and quality of life impact
  • Treatment goals and expected outcomes

Prior Treatment History:

  • Each DMARD tried with dates, doses, and duration
  • Specific reasons for discontinuation (inefficacy, intolerance, contraindications)
  • Any biologic trials if required by step therapy
  • Documentation of treatment failures with objective measures

Safety Considerations:

  • Recent tuberculosis and hepatitis B screening results
  • Current infection status
  • Contraindications to formulary alternatives
  • Monitoring plan during Kineret therapy

Supporting Evidence:

  • FDA prescribing information for approved indications
  • ACR guidelines for RA management
  • Published studies for off-label uses (if applicable)

The Appeals Process in Washington

Step-by-Step Appeals Playbook

Level 1: Internal Appeal

  1. File within deadline (60-180 days from denial)
  2. Submit via preferred method (online portal, fax, or mail)
  3. Include all documentation (medical necessity letter, clinical notes, lab results)
  4. Request expedited review if medically urgent (72-hour decision)
  5. Timeline: Standard appeals decided within 30 days

Level 2: Second Internal Appeal

  • Available for most commercial plans
  • Same documentation requirements as Level 1
  • Often reviewed by different medical director
  • Timeline: 30-60 days for decision

Peer-to-Peer Review:

  • Available during internal appeals process
  • Prescribing physician speaks directly with plan medical director
  • Schedule through prior authorization number on denial letter
  • Focus on clinical rationale and failed alternatives
From our advocates: We've seen many Kineret denials overturned at peer-to-peer review when the prescribing rheumatologist clearly explains why TNF inhibitors are contraindicated due to heart failure or recurrent infections. Having specific dates and clinical markers ready makes these calls much more effective.

External Review Through IRO

Washington's Independent Review Organization process offers strong patient protections:

When You Can Request External Review

  • After completing internal appeals (or if plan misses deadlines)
  • For medical necessity disputes
  • For experimental/investigational treatment denials
  • Within 60 days of final internal denial

Timeline and Process

Standard External Review:

  • Request through your health plan, not directly with IRO
  • Plan assigns certified IRO within 3 business days
  • You have 5+ business days to submit additional information
  • Decision within 20 days (fully insured) or 45 days (self-insured)

Expedited External Review:

  • Available if delay would seriously jeopardize health
  • Decision within 72 hours
  • Clearly document urgent medical need in request

Required Documentation

  • Copy of denial letter showing final internal decision
  • Medical necessity letter from prescriber
  • Clinical notes and lab results
  • Any supporting literature or guidelines
  • Prior authorization forms and responses

The IRO decision is binding on the insurance plan. Success rates for specialty medication appeals often exceed 50% when clinical documentation is thorough.

Common Denial Reasons and Solutions

Denial Reason Solution Strategy Documentation Needed
Step therapy not completed Document failed/contraindicated preferred agents Treatment history with dates, doses, outcomes
Not medically necessary Strengthen clinical rationale Disease activity measures, functional assessments
Experimental/investigational Provide compendia support FDA label, peer-reviewed studies, guidelines
Quantity limits exceeded Justify dosing requirements Weight-based calculations, specialist recommendation
Active infection concern Update screening results Recent TB and hepatitis B tests, infection status

Cost-Saving Options

While pursuing coverage, consider these financial assistance programs:

Manufacturer Support:

Foundation Grants:

  • Disease-specific foundations for RA and autoinflammatory conditions
  • State pharmaceutical assistance programs
  • Hospital charity care programs

Alternative Coverage:

  • Medicare Part B coverage for certain indications
  • Medicaid coverage with different criteria
  • Clinical trial participation

When to Contact Regulators

Contact the Washington Office of the Insurance Commissioner if:

  • Your plan violates appeal timelines
  • You need help understanding your rights
  • External review is improperly denied
  • You want to file a complaint about claims handling

Consumer Advocacy Line: 1-800-562-6900 Online complaint portal: Available on OIC website Timeline: File complaints within 3 years of the issue

Frequently Asked Questions

How long does Blue Cross Blue Shield prior authorization take in Washington? Standard PA decisions are typically made within 7-14 business days. Expedited requests for urgent cases must be decided within 72 hours.

What if Kineret is non-formulary on my plan? Request a formulary exception by demonstrating medical necessity and failure/contraindication to formulary alternatives. Include supporting clinical literature.

Can I request an expedited appeal if I'm already on Kineret? Yes, if interrupting therapy would seriously jeopardize your health or ability to regain maximum function. Document the clinical urgency clearly.

Does step therapy apply if I failed these drugs with a different insurer? Medical records showing previous failures should satisfy step therapy requirements. Ensure documentation includes specific dates, doses, and reasons for discontinuation.

What happens if my external review is denied? The IRO decision is final for the insurance dispute, but you may have other options like filing complaints with regulators or seeking legal counsel for complex cases.

How much does Kineret cost without insurance in Washington? Retail prices vary by pharmacy but can exceed $2,000 per month. Manufacturer assistance programs and patient foundations may help reduce costs while pursuing coverage.

Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Kineret. Our platform analyzes denial letters, identifies specific coverage criteria, and generates evidence-backed appeals that address each payer's requirements. For patients and clinicians navigating prior authorization challenges, we provide the targeted documentation and strategic approach that significantly improves approval rates.

Getting Kineret covered requires persistence and thorough documentation, but Washington's strong consumer protections—including specialist-matched reviewers and binding external review—give patients real leverage in the appeals process. With proper preparation and use of all available appeal levels, many patients successfully obtain coverage even after initial denials. The key is understanding your specific plan's requirements and building a comprehensive clinical case that addresses each coverage criterion.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and change over time. Always consult your healthcare provider about treatment decisions and verify current coverage requirements with your insurance plan. For personalized assistance with appeals, contact the Washington Office of the Insurance Commissioner or qualified patient advocacy services.

Sources & Further Reading

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.