By Counterforce Health Team in Opdivo (nivolumab) —

How to Get Opdivo (nivolumab) Covered by Blue Cross Blue Shield in Pennsylvania: Complete Forms, Appeals & Contact Guide

Answer Box: Getting Opdivo Covered by Blue Cross Blue Shield in Pennsylvania

First step: Verify your exact Blue Cross plan (Highmark vs. Independence Blue Cross) and check if Opdivo requires prior authorization for your specific coverage. Fastest approval path: Submit a complete prior authorization request with cancer diagnosis, staging, prior treatment failures, and biomarker results through your plan's provider portal or specialty pharmacy network. Timeline: Standard PA decisions within 30 days; expedited reviews within 48-72 hours for urgent cases. If denied, you have 180 days for internal appeals and 4 months for Pennsylvania's Independent External Review program, which overturns about 50% of denials.

Table of Contents

  1. Start Here: Verify Your Blue Cross Plan
  2. Prior Authorization Forms & Requirements
  3. Submission Portals & Electronic Tools
  4. Fax Numbers & Mailing Addresses
  5. Specialty Pharmacy Network
  6. Support Phone Lines & Contacts
  7. Pennsylvania Appeals & Consumer Help
  8. When to Update Your Information

Start Here: Verify Your Blue Cross Plan

Pennsylvania has two major Blue Cross Blue Shield entities with different policies and forms:

Highmark Blue Cross Blue Shield

  • Coverage areas: Western, Central, and Northeastern Pennsylvania
  • Plans include: Commercial PPO/HMO, Medicare Advantage, Medicaid (Highmark Health Options)
  • Provider portal: Highmark Provider Resource Center
  • Member portal: Highmark.com member login

Independence Blue Cross (IBX)

  • Coverage area: Southeastern Pennsylvania (Philadelphia region)
  • Plans include: Personal Choice, Keystone HMO, Medicare Advantage
  • Provider portal: IBX Provider Communications
  • Member portal: IBX.com member login
Tip: Check your insurance card for "Highmark" or "Independence" branding, or look for the specific plan name to determine which entity manages your coverage.

What you need to confirm:

  • Exact plan name and product type (Commercial vs. Medicare vs. Medicaid)
  • Whether Opdivo requires prior authorization for your specific plan
  • If the drug is covered under medical benefit (infusion) or pharmacy benefit

Prior Authorization Forms & Requirements

Highmark Blue Cross Blue Shield

Opdivo requests use the standard Prescription Drug/Medication Request form for pharmacy benefit or medical prior authorization forms for infusion billing.

Where to find current forms:

  1. Go to Highmark Provider Resource Center
  2. Navigate to Resources & Education → Forms → Pharmacy Prior Authorization Forms
  3. Select your line of business (Commercial/Medicare Advantage/ACA Exchange)
  4. Choose Pennsylvania region (not WV/DE)

Required clinical documentation:

  • Member information (name, DOB, ID, plan type)
  • Prescriber details (NPI, oncology specialty, contact info)
  • Drug specifics (nivolumab dose, route, frequency, duration)
  • Diagnosis with ICD-10 code matching FDA-approved indications:
    • Unresectable/metastatic melanoma
    • Non-small cell lung cancer (NSCLC)
    • Renal cell carcinoma
    • Hodgkin lymphoma
    • Head and neck squamous cell carcinoma
  • Clinical status: Stage, resectable vs. unresectable, line of therapy
  • Prior treatments: Previous chemotherapy, targeted therapy, immunotherapy with reasons for discontinuation
  • Biomarker results: PD-L1 expression, MSI-H, TMB-H status where applicable
  • Performance status: ECOG or Karnofsky score
  • Safety considerations: No contraindications, immune-related adverse event history

Independence Blue Cross (IBX)

IBX maintains a specific medical policy for nivolumab that outlines coverage criteria.

Key requirements from IBX policy:

  • Confirmed diagnosis appropriate for FDA-approved or NCCN-compendium indications
  • Documentation that standard first-line therapies have failed, are contraindicated, or inappropriate
  • Clear line of therapy designation (first-line vs. subsequent)
  • Biomarker testing results where clinically relevant
  • Performance status adequate for outpatient infusion
Note: IBX does not use traditional step therapy for oncology drugs but embeds "functional step therapy" within medical necessity criteria.

Submission Portals & Electronic Tools

Highmark Electronic Submission

  • Provider portal: Highmark authorization tools
  • Preferred method: Online submission through provider portal
  • Account required: Yes, provider registration needed
  • Supporting documents: Upload clinical notes, lab results, imaging reports

Independence Blue Cross Electronic Options

  • Precertification: Through IBX provider portal for specialty drugs under medical benefit
  • Phone option: Call member services number on ID card to start coverage request
  • Formulary tool: Find a covered prescription drug to check PA requirements

Medicare Plans

  • Both Highmark Medicare and IBX Medicare may have separate authorization portals
  • Check your specific Medicare Advantage plan documents for submission methods

Fax Numbers & Mailing Addresses

Important: Fax numbers and addresses change frequently. Always verify current contact information on your most recent prior authorization form or by calling member services.

Highmark Fax Submission

  • Fax numbers are listed on the current PA forms (varies by line of business)
  • Include cover sheet with member ID, prescriber NPI, and drug name
  • Request fax confirmation receipt

Independence Blue Cross Contacts

  • Expedited appeals fax: 1-888-289-3008
  • Standard appeals phone: 1-800-645-3965
  • Expedited phone: 1-888-718-3333

General Tips for Fax Submission

  • Send during business hours for faster processing
  • Include complete member identification on every page
  • Keep fax confirmation receipts
  • Follow up within 3-5 business days if no acknowledgment received

Specialty Pharmacy Network

Opdivo is typically dispensed through network specialty pharmacies and shipped to your infusion center ("white bagging").

Highmark Specialty Pharmacy Partners (Examples)

  • Diplomat Specialty Pharmacy – Boothwyn, PA: 484-448-6019
  • PantherRx Specialty Pharmacy – Pittsburgh, PA: 855-726-8479
  • Coordinated Care Network Pharmacy – Pittsburgh, PA: 877-349-6330
  • Lehigh Valley Pharmacy Services – Bethlehem, PA: 484-884-7004
  • Walgreens Specialty Pharmacy – Pittsburgh, PA: 412-413-8000

Finding Your In-Network Options

  1. Use Highmark Pharmacy Finder and filter for "Specialty Pharmacy"
  2. For IBX, use Find a pharmacy tool and select specialty network
  3. Confirm with your oncology provider which specialty pharmacies they accept shipments from

Specialty Pharmacy Setup Process

  1. Your oncology office typically handles initial enrollment
  2. Provide insurance information and prescription
  3. Specialty pharmacy obtains prior authorization if not already approved
  4. Drug is shipped directly to infusion center
  5. Coordinate delivery timing with your treatment schedule

Support Phone Lines & Contacts

Member Services (General Questions)

  • Highmark: Number on back of member ID card
  • Independence Blue Cross: Number on back of member ID card
  • What to ask:
    • "Does my plan require prior authorization for Opdivo (nivolumab)?"
    • "Which specialty pharmacies are in-network for my plan?"
    • "What is the status of my prior authorization request?"

Provider Relations (For Clinics)

  • Highmark Provider Services: Available through provider portal
  • IBX Provider Relations: Contact through provider communications portal
  • What clinics should ask:
    • Current PA form version and submission method
    • Medical necessity criteria for specific cancer diagnoses
    • Expedited review process for urgent cases

Case Management

  • Available for complex cases requiring coordination
  • Can help navigate specialty pharmacy enrollment
  • May assist with appeal preparation and peer-to-peer reviews

Pennsylvania Appeals & Consumer Help

Internal Appeals Process

Timeline for Blue Cross appeals:

  • File within: 180 days of denial notice
  • Standard review: 30 days for decision
  • Expedited review: 48 hours (if delay jeopardizes life/health)
  • Who can file: Patient, provider, or authorized representative

Pennsylvania Independent External Review

After exhausting internal appeals, you can request external review through the Pennsylvania Insurance Department.

Key details:

  • Deadline: 4 months after Final Adverse Benefit Determination
  • Success rate: Approximately 50% of appeals overturned in favor of patients
  • Timeline: 45 days for standard review, 72 hours for expedited
  • Submission: Online portal preferred, or mail/fax forms

Pennsylvania Health Law Project (PHLP)

  • Phone: 1-800-274-3258
  • Email: [email protected]
  • Services: Free legal assistance for health insurance appeals
  • Expertise: Medicaid, commercial insurance, and specialty drug denials

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals using the right medical evidence and citations.

When to Escalate to Regulators

  • Pennsylvania Insurance Department Consumer Services: For plan violations or procedural issues
  • Contact if: Insurer misses deadlines, refuses to process appeals, or violates state regulations
  • File complaint: Through PA.gov insurance complaint portal

When to Update Your Information

Quarterly Checks (Every 3 Months)

  • Review formulary updates for tier changes
  • Check for new prior authorization requirements
  • Verify specialty pharmacy network status

Annual Updates (January)

  • Download new PA forms for the current year
  • Review updated medical policies
  • Confirm provider portal access and credentials

Immediate Updates Needed When:

  • Switching insurance plans or employers
  • Moving to different regions within Pennsylvania
  • Changing from commercial to Medicare coverage
  • Prior authorization expires and needs renewal
Important: Insurance policies and formularies can change mid-year with proper notice. Always check current requirements before submitting new requests.

Coverage at a Glance

Requirement Highmark BCBS Independence Blue Cross Where to Verify
Prior Authorization Yes (most plans) Yes (precertification required) Member portal or PA form
Formulary Status Varies by plan Medical benefit coverage Drug lookup tool
Step Therapy Embedded in medical criteria Functional step therapy in policy Medical policy documents
Specialty Pharmacy Required for pharmacy benefit Network restrictions apply Pharmacy finder tool
Appeals Deadline 180 days 180 days Denial letter

Frequently Asked Questions

How long does Blue Cross PA take in Pennsylvania? Standard prior authorization decisions are made within 30 days. Expedited reviews for urgent cases are completed within 48-72 hours.

What if Opdivo is non-formulary on my plan? You can request a formulary exception by demonstrating medical necessity and providing documentation that formulary alternatives are inappropriate or have failed.

Can I request an expedited appeal? Yes, if delay in treatment could jeopardize your life, health, or ability to regain maximum function. Your doctor must provide clinical justification for urgency.

Does step therapy apply if I've tried treatments outside Pennsylvania? Yes, prior treatment history from other states should be accepted as long as you provide adequate documentation of therapies tried and outcomes.

What happens if my external review is approved? The insurer must immediately provide coverage for the treatment, including potential retroactive coverage if you paid out-of-pocket during the appeal.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with your specific plan and consult with your healthcare provider about treatment decisions. For personalized assistance with appeals, contact the Pennsylvania Health Law Project or other qualified consumer advocacy organizations.

Need help with your appeal? Counterforce Health provides comprehensive support for turning insurance denials into successful appeals by analyzing your specific denial and crafting evidence-based responses tailored to your insurer's requirements.

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