By Counterforce Health Team in Opsumit (macitentan) —

How to Get Opsumit (Macitentan) Covered by Blue Cross Blue Shield of Texas: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Opsumit Covered by BCBS Texas

Blue Cross Blue Shield of Texas requires prior authorization for Opsumit (macitentan). Your doctor must submit a PA request through the BCBS provider portal or Availity, documenting your PAH diagnosis and any failed prior treatments. If denied, you have 180 days to file an internal appeal, followed by independent external review through the Texas Department of Insurance if needed.

Start today: Have your prescriber initiate the PA request via BCBS Texas provider portal with complete clinical documentation.

Table of Contents

Verify Your Plan Coverage

Before starting the prior authorization process, confirm Opsumit's status on your specific BCBS Texas plan. Opsumit (macitentan) appears on BCBS Texas specialty drug lists and requires prior authorization across most commercial plans.

Coverage at a Glance:

Requirement What It Means Where to Find It
Prior Authorization Required Doctor must get approval before prescribing BCBS Texas PA Codes List
Specialty Pharmacy Must use BCBS-contracted specialty pharmacy BCBS Specialty Program
Medical Necessity Must meet FDA-approved PAH indication Your plan's drug formulary
REMS Program Opsumit requires Risk Evaluation and Mitigation Strategy enrollment FDA/Janssen requirements

Check your specific plan's formulary by logging into your member portal at bcbstx.com or calling the number on your insurance card.

Prior Authorization Forms and Requirements

Your prescriber must submit a comprehensive prior authorization request that includes specific clinical documentation for PAH treatment.

Required Documentation

Clinical Information Needed:

  • PAH diagnosis with WHO functional class
  • Echocardiogram or right heart catheterization results
  • 6-minute walk test results (if available)
  • Complete medication history, including:
    • Previous PAH treatments tried and outcomes
    • Reasons for discontinuation or failure
    • Any contraindications to preferred alternatives

REMS Requirements:

  • Confirmation of negative pregnancy test (for females of reproductive potential)
  • Contraception counseling documentation
  • Provider certification of REMS program enrollment
Tip: Include all out-of-state treatment records. Failed therapies from other states count toward step therapy requirements.

Medical Necessity Letter Components

Your prescriber's letter should address:

  1. Clinical rationale: Why Opsumit is medically necessary for your specific case
  2. Prior therapy failures: Documented trials of preferred alternatives with specific reasons for discontinuation
  3. Contraindications: Any medical reasons why formulary alternatives aren't appropriate
  4. Treatment goals: Expected outcomes and monitoring plan
  5. Guidelines support: Reference to AHA/ATS PAH guidelines or other recognized standards

Submission Portals and Methods

BCBS Texas uses multiple submission channels depending on your plan type and the prescriber's preference.

Online Submission

Alternative Submission Methods

If online submission isn't available:

  • Fax: Check your specific plan's PA fax number (varies by plan)
  • Mail: Use the address provided in your plan documents
  • Phone: Initial requests can sometimes be started by phone, but written documentation is always required
Note: Always use the most current forms from the official BCBS Texas website, as requirements are updated regularly.

Specialty Pharmacy Requirements

Opsumit must be dispensed through a BCBS Texas-contracted specialty pharmacy for coverage.

Accredo Specialty Pharmacy

BCBS Texas primarily contracts with Accredo for self-administered specialty medications like Opsumit.

Transfer Process:

  1. Your prescriber e-prescribes to Accredo (NCPDP ID: 4436920)
  2. Complete Accredo's patient enrollment process
  3. Provide insurance and clinical information
  4. Coordinate delivery and counseling services

Accredo Contact:

  • Phone: 1-800-803-2523
  • Provider portal: accredo.com/prescribers

What Accredo Handles

  • Prior authorization coordination with BCBS Texas
  • REMS program enrollment and monitoring
  • Patient education and adherence support
  • Delivery coordination and refill management

When Prior Authorization is Denied

If your initial PA request is denied, you'll receive a denial letter explaining the specific reasons. Common denial reasons include:

Common Denial Reasons and Solutions:

Denial Reason How to Address
Insufficient clinical documentation Submit complete treatment history, diagnostic results, and functional assessments
Step therapy not met Document trials and failures of preferred alternatives (ambrisentan, bosentan)
REMS requirements not met Provide pregnancy testing results and contraception counseling documentation
Off-label use Submit literature supporting use and medical necessity letter

Appeals Process in Texas

Texas law provides robust appeal rights for specialty drug denials, including access to independent external review.

Internal Appeal Process

Step 1: File Internal Appeal

  • Deadline: 180 days from denial notice
  • How to submit: Written appeal with supporting documentation
  • Timeline: 30 days for standard review, 72 hours for expedited

Required for Appeal:

  • Copy of original denial letter
  • Updated medical necessity letter from prescriber
  • Additional clinical documentation addressing denial reasons
  • Any new relevant medical literature

External Review (Independent Review Organization)

If your internal appeal is denied, Texas law provides access to independent external review.

IRO Process:

  • Eligibility: Available for medical necessity denials
  • Deadline: 45 days after final internal denial
  • Form: LHL009 (provided with denial letter)
  • Timeline: 20 days for standard review, 8 days for life-threatening cases
  • Cost: Free to patient (insurer pays IRO fees)

Submit IRO Request:

  1. Complete form LHL009 provided with your final denial
  2. Include all supporting medical documentation
  3. Submit to BCBS Texas (they forward to Texas Department of Insurance)
  4. IRO decision is binding on the insurer
From our advocates: We've seen cases where comprehensive documentation of functional decline and specific contraindications to alternatives led to successful IRO reversals, even after initial internal appeal denials. The key is presenting a complete clinical picture that clearly demonstrates medical necessity.

Contact Information and Support

BCBS Texas Member Services

  • Individual/Family Plans: 1-888-697-0683
  • Group PPO/POS Plans: 1-800-521-2227
  • HMO Blue Texas: 1-877-299-2377
  • Hours: Monday-Friday 7 AM - 8 PM, Saturday 8 AM - 5 PM

Specialty Drug Support

Call the main customer service number and request connection to:

  • Case management team
  • Specialty pharmacy coordinator
  • Prior authorization department

Texas Department of Insurance

  • IRO Information: 1-866-554-4926
  • Consumer Helpline: 1-800-252-3439
  • Website: tdi.texas.gov

Accredo Specialty Pharmacy

  • Patient Services: 1-800-803-2523
  • Provider Support: Available through provider portal
  • Hours: 24/7 for urgent needs

Cost-Saving Options

Even with insurance coverage, Opsumit can be expensive. Several programs can help reduce your costs:

Manufacturer Support

Janssen CarePath:

  • Copay assistance for eligible commercially insured patients
  • May reduce copay to as low as $5 per month
  • Patient support services and adherence programs
  • Website: janssencarepath.com

Foundation Assistance

  • Patient Access Network Foundation: Provides grants for PAH medications
  • HealthWell Foundation: Copay assistance for qualifying patients
  • Good Days: Financial assistance for chronic disease medications

State Programs

Texas residents may qualify for additional assistance through state pharmaceutical assistance programs (verify current availability with Texas Health and Human Services).

FAQ

How long does BCBS Texas prior authorization take for Opsumit? Standard PA decisions are issued within 14 business days. Expedited reviews (when delay would jeopardize health) are decided within 72 hours.

What if Opsumit isn't on my plan's formulary? You can request a formulary exception through the same PA process, but you'll need stronger documentation showing medical necessity and why formulary alternatives aren't appropriate.

Can I get expedited review for my PA or appeal? Yes, if your doctor certifies that a delay would seriously jeopardize your health or ability to regain maximum function. Mark requests as "urgent" with clinical justification.

Do I need to use Accredo for Opsumit? For most BCBS Texas plans, yes. Opsumit is typically covered only when dispensed through contracted specialty pharmacies like Accredo.

What happens if I'm already stable on Opsumit and get denied? Request "continuity of care" coverage to continue therapy during the appeal process. File this request within 10 days of denial with provider support.

How much does Opsumit cost without insurance? Opsumit's list price is typically in the five-figure range annually. Exact costs vary, but manufacturer copay programs can significantly reduce out-of-pocket expenses for eligible patients.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Opsumit. Our platform analyzes denial letters, identifies specific coverage criteria, and generates evidence-backed appeals that address payer requirements point-by-point. We help patients, clinicians, and specialty pharmacies navigate the prior authorization process more effectively, reducing the time and complexity involved in getting specialty medications approved.

For additional support with your Opsumit appeal, Counterforce Health provides tools and guidance to strengthen your case with the right clinical evidence and payer-specific documentation.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage and appeal processes can vary by plan and may change over time. Always consult with your healthcare provider and insurance plan for the most current requirements and procedures. For questions about Texas insurance regulations, contact the Texas Department of Insurance.

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