By Counterforce Health Team in Mavenclad (cladribine tablets) —

How to Get Mavenclad (Cladribine Tablets) Covered by Blue Cross Blue Shield of Illinois: Requirements, Forms & Appeal Process

Answer Box: Getting Mavenclad Covered by BCBS Illinois

Yes, Blue Cross Blue Shield of Illinois covers Mavenclad (cladribine tablets) with prior authorization. The fastest path: (1) Verify your plan requires PA through Availity Essentials, (2) Submit complete clinical documentation showing relapsing MS diagnosis (ICD-10: G35.A or G35.C1) and lymphocyte count ≥800 cells/μL, and (3) Use Accredo specialty pharmacy for preferred coverage. Start today: Call BCBS member services at the number on your ID card to confirm your specific plan's requirements and formulary status.

Table of Contents

Who Should Use This Guide

This comprehensive checklist is designed for Illinois residents with Blue Cross Blue Shield coverage who need Mavenclad (cladribine tablets) for relapsing forms of multiple sclerosis. You'll also find this helpful if you're a healthcare provider submitting prior authorization requests or appealing denials.

Expected outcome: With proper documentation and submission, most medically appropriate Mavenclad requests get approved within 15 business days. If initially denied, strong clinical evidence significantly improves appeal success rates.

Member & Plan Basics

Coverage Verification Steps

Before starting your prior authorization request:

  1. Confirm active coverage - Log into Blue Access for Members or call the member services number on your ID card
  2. Check your specific plan type - BCBS Illinois includes HMO, PPO, Medicaid, and Medicare Advantage plans with different requirements
  3. Verify deductible status - High-cost specialty drugs like Mavenclad may apply to your deductible before coverage begins
  4. Confirm prior authorization requirement - Use the BCBS Illinois drug lookup tool to verify current PA requirements
Note: As of July 2024, BCBS Illinois requires prior authorization for Mavenclad across most government and commercial plans.

Clinical Criteria for Approval

FDA-Approved Indications

Mavenclad is approved for relapsing forms of multiple sclerosis in adults, including:

  • Relapsing-remitting MS (RRMS)
  • Active secondary progressive MS (SPMS)

Key Clinical Requirements

Requirement Details Documentation Needed
Diagnosis Relapsing forms of MS confirmed by neurologist MRI reports, clinical notes, MS subtype classification
Lymphocyte Count ≥800 cells/μL at baseline Recent complete blood count (within 30 days)
Pregnancy Status Negative pregnancy test; effective contraception plan Lab results, contraception documentation
Prior Treatments May require documentation of previous DMT trials Treatment history, reasons for discontinuation
Contraindications No current malignancy or immunodeficiency Medical history review, oncology clearance if applicable
Clinician Corner: BCBS Illinois typically requires documentation that Mavenclad is prescribed according to FDA labeling, including the cumulative 3.5 mg/kg dosing over two annual treatment courses.

Coding & Billing Requirements

Essential Codes for Claims Processing

ICD-10 Diagnosis Codes (2025):

  • G35.A - Relapsing-remitting multiple sclerosis
  • G35.C1 - Secondary progressive multiple sclerosis with relapses (active SPMS)

Billing Codes:

  • HCPCS Code: J8499 (oral prescription drugs)
  • NDC Codes: 44087-4000-0 through 44087-4000-9 (10 mg tablets)

Coding Best Practices

  • Use the most specific MS subtype code available
  • Avoid unspecified codes (G35) unless subtype is truly unknown
  • Include relevant comorbidity codes that support medical necessity

Documentation Packet

Required Clinical Documentation

Your provider must submit:

  1. Comprehensive medical history including:
    • MS diagnosis date and subtype
    • Previous DMT trials and outcomes
    • Current EDSS score (if available)
    • Recent MRI findings
  2. Laboratory results:
    • Complete blood count with differential (within 30 days)
    • Liver function tests
    • Pregnancy test results (if applicable)
  3. Letter of Medical Necessity including:
    • Patient demographics and insurance information
    • Detailed MS history and current status
    • Rationale for Mavenclad selection
    • Expected treatment plan and monitoring schedule
    • Provider signature and NPI number

Medical Necessity Letter Template

Patient: [Name, DOB, Member ID]
Diagnosis: Relapsing-remitting multiple sclerosis (ICD-10: G35.A)

Clinical History: [Patient name] was diagnosed with RRMS on [date] and has experienced [number] relapses in the past [timeframe]. Previous treatments include [list DMTs tried] with [outcomes/reasons for discontinuation].

Current Status: Recent MRI shows [findings]. Patient's current EDSS score is [score]. Lymphocyte count is [value] cells/μL (normal range).

Medical Necessity: Mavenclad is medically necessary for this patient because [specific clinical rationale]. The patient meets FDA criteria for relapsing forms of MS and has [baseline lab requirements met/contraindications addressed].

Treatment Plan: Mavenclad will be administered as 3.5 mg/kg cumulative dose over two annual courses with appropriate monitoring per FDA guidelines.

[Provider signature, date, NPI]

Submission Process

Electronic Submission (Preferred Method)

Primary Portal: Availity Essentials

  1. Log in with your provider credentials
  2. Navigate to "Authorizations" tool
  3. Search for member and select Mavenclad
  4. Complete all required fields
  5. Upload supporting documentation
  6. Submit and record confirmation number

Alternative: BlueApprovR (for commercial non-HMO plans)

Paper Submission

If electronic submission isn't available:

  • Download current PA form from BCBS Illinois provider portal
  • Complete all sections thoroughly
  • Attach all supporting documentation
  • Fax to number provided on form (verify current fax number)
Tip: Electronic submissions typically process faster and provide real-time tracking capabilities.

Specialty Pharmacy Requirements

Preferred Network Pharmacy

Accredo Specialty Pharmacy is the preferred vendor for BCBS Illinois members:

  • Provider contact: 833-721-1619
  • Prescriber portal: accredo.com/prescribers
  • Benefits: Lowest out-of-pocket costs, streamlined prior authorization coordination

Alternative In-Network Options

  • AcariaHealth Specialty Pharmacy
  • Advanced Pharmacy Solutions
  • AllCare Specialty Pharmacy
  • BioPlus Specialty Services
Important: Using out-of-network specialty pharmacies may result in significantly higher costs or no coverage.

After Submission: Tracking Your Request

Timeline Expectations

  • Standard requests: 15 business days maximum
  • Expedited requests: 24-72 hours (urgent medical situations)
  • Status checks: Available through submission portal or member services

What to Track

  1. Confirmation number from initial submission
  2. Request status (pending, approved, denied, need more info)
  3. Communication from BCBS via portal, mail, or phone
  4. Specialty pharmacy coordination once approved

Common Denial Reasons & How to Avoid Them

Denial Reason Prevention Strategy If Denied, Submit
Incomplete clinical information Submit comprehensive medical history and current status Additional clinical notes, recent MRI reports
Laboratory requirements not met Ensure lymphocyte count ≥800 cells/μL documented Updated lab results within normal parameters
Step therapy not satisfied Document previous DMT trials and outcomes Detailed treatment history with failure/intolerance reasons
Diagnosis not supported Use specific ICD-10 codes with supporting documentation Neurologist confirmation, diagnostic imaging
Pregnancy/contraception concerns Include pregnancy test and contraception plan Gynecology consultation, contraception documentation

Appeals Process in Illinois

Internal Appeal (First Level)

Timeline: Must file within 180 days of denial Process:

  1. Submit appeal through BCBS Illinois member portal or written request
  2. Include additional clinical evidence addressing denial reasons
  3. Request peer-to-peer review with neurologist if appropriate Decision timeframe: 15 business days (24 hours if expedited)

External Review (Independent Review)

Timeline: Must request within 30 days of final internal appeal denial Process:

  1. Contact Illinois Department of Insurance at 877-527-9431
  2. Submit external review application
  3. Independent physician reviewer evaluates case Decision timeframe: 5 business days after IRO receives all materials
Illinois-Specific: The 30-day external review deadline is shorter than many states' 4-month window, so act promptly after internal appeal denials.

State Resources for Help

  • Illinois Department of Insurance Office of Consumer Health Insurance: 877-527-9431
  • Illinois Attorney General Health Care Helpline: 877-305-5145
  • Legal aid organizations for complex cases requiring additional advocacy

When navigating complex insurance appeals, platforms like Counterforce Health can help transform denial letters into targeted, evidence-backed appeals by analyzing your specific plan's policies and crafting point-by-point rebuttals aligned to your insurer's own rules.

Costs & Patient Assistance

Manufacturer Support

EMD Serono offers patient assistance programs:

  • Mavenclad Patient Support: Financial assistance for eligible patients
  • Copay assistance: May reduce out-of-pocket costs for commercially insured patients
  • Contact: Visit mavenclad.com for current programs

Additional Resources

  • National MS Society: Financial assistance programs
  • Patient Access Network Foundation: Grants for MS medications
  • State pharmaceutical assistance programs: Check Illinois-specific options

FAQ

How long does BCBS Illinois prior authorization take for Mavenclad? Standard requests must be processed within 15 business days. Expedited requests for urgent medical situations are processed within 24-72 hours.

What if Mavenclad is not on my plan's formulary? You can request a formulary exception by demonstrating medical necessity and providing evidence that preferred alternatives are inappropriate for your specific case.

Can I get an expedited appeal if my condition is worsening? Yes, if a delay would seriously jeopardize your health, you can request an expedited internal appeal (24-hour decision) and expedited external review if needed.

Do I need to use Accredo specialty pharmacy? While not always required, using Accredo typically results in the lowest out-of-pocket costs and streamlined coordination with BCBS Illinois.

What happens if I'm pregnant or planning pregnancy? Mavenclad is contraindicated in pregnancy. Your provider must document effective contraception and negative pregnancy testing before approval.

Can I appeal if I've been denied multiple times? Yes, you can request external review through the Illinois Department of Insurance after exhausting internal appeals, regardless of previous denials.

The information in this guide is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. Counterforce Health helps patients and providers navigate complex prior authorization and appeals processes by turning insurance denials into targeted, evidence-backed appeals.

Sources & Further Reading

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