By Counterforce Health Team in Orladeyo (berotralstat) —

How to Get Orladeyo (Berotralstat) Covered by Blue Cross Blue Shield of Michigan: Complete Forms, Appeals, and Approval Guide

Answer Box: Getting Orladeyo Covered by Blue Cross Blue Shield of Michigan

Quick path to approval: Orladeyo (berotralstat) requires prior authorization from Blue Cross Blue Shield of Michigan for hereditary angioedema prophylaxis. Submit through your doctor via the BCBS Michigan provider portal with complete HAE diagnosis documentation, C1-INH levels, and specialist evaluation. If denied, you have 180 days for internal appeals and 127 days for Michigan DIFS external review. Start today: Contact your HAE specialist to gather required clinical documentation and confirm your specific BCBS Michigan formulary status.

Table of Contents

  1. Start Here: Verify Your Plan and Coverage
  2. Required Forms and Documentation
  3. Submission Portals and Electronic Filing
  4. Fax and Mail Submission Details
  5. Specialty Pharmacy Network Requirements
  6. Support Lines and Contact Information
  7. Michigan Appeals and External Review Process
  8. Common Denial Reasons and How to Fix Them
  9. Costs and Patient Assistance Programs
  10. When to Escalate to State Regulators
  11. Frequently Asked Questions

Start Here: Verify Your Plan and Coverage

Before starting your Orladeyo prior authorization, confirm your specific Blue Cross Blue Shield of Michigan coverage details. BCBS Michigan operates multiple plan types with different formularies and requirements.

Step 1: Check Your Formulary Status Log into your BCBS Michigan member portal or review your current Preferred Drug List to see if Orladeyo appears and what tier it's classified under.

Step 2: Identify Your Plan Type

  • Commercial PPO/HMO: Standard prior authorization process
  • Medicare Advantage: May have additional CMS requirements
  • Blue Care Network: Specific BCN formulary applies
Note: BCBS Michigan covers approximately 67% of commercial plan members in the state, making it the dominant insurer for HAE patients seeking Orladeyo coverage.

Required Forms and Documentation

Core Prior Authorization Requirements

Your healthcare provider must submit a complete prior authorization request including:

Patient Information:

  • Full name, date of birth, member ID
  • Complete contact information
  • Primary care physician details

Clinical Documentation:

  • ICD-10 diagnosis codes for hereditary angioedema
  • C1-INH functional and antigenic levels
  • Genetic testing results (if applicable for HAE with normal C1-INH)
  • HAE specialist evaluation from immunologist or allergist

Treatment History:

  • Previous prophylaxis medications tried and outcomes
  • Attack frequency and severity documentation
  • Contraindications to alternative therapies (Takhzyro, Haegarda, Cinryze)
  • Current on-demand therapy usage

Medical Necessity Letter Checklist

Your specialist should include these elements in the medical necessity letter:

  • Problem statement: HAE attack frequency and impact on quality of life
  • Prior treatments: Specific medications tried, duration, and reasons for discontinuation
  • Clinical rationale: Why Orladeyo is medically necessary for this patient
  • Guideline support: Reference to World Allergy Organization HAE guidelines and FDA labeling
  • Monitoring plan: How treatment response will be assessed

Submission Portals and Electronic Filing

Provider Portal Access

Healthcare providers submit Orladeyo prior authorization requests through Availity Essentials, the official BCBS Michigan provider portal.

Access steps:

  1. Log in to availity.com
  2. Click "Payer Spaces" in the menu
  3. Select the BCBSM and BCN logo
  4. Navigate to the e-referral system

Processing timeframes:

  • Standard requests: 5-7 business days
  • Urgent requests: 24-48 hours
Tip: Electronic submission through the provider portal typically processes faster than fax or phone submissions.

Required Electronic Uploads

When submitting electronically, ensure these documents are attached:

  • Complete prior authorization form
  • Medical necessity letter
  • Lab results (C1-INH levels)
  • Specialist consultation notes
  • Previous treatment records

Fax and Mail Submission Details

Alternative Submission Methods

If electronic submission isn't available, providers can use:

Fax submission: Use the designated fax number listed on the BCBS Michigan prior authorization form (verify current number on form)

Mail submission: Blue Cross Blue Shield of Michigan Prior Authorization Department 600 E. Lafayette Blvd, Mail Code 2004 Detroit, Michigan 48226-2998

Cover sheet recommendations:

  • Include "URGENT - HAE MEDICATION REQUEST" if expedited review needed
  • List all attached documents
  • Provide direct callback number for questions

Specialty Pharmacy Network Requirements

BCBS Michigan Specialty Pharmacy Network

Orladeyo must be dispensed through BCBS Michigan's contracted specialty pharmacy network, primarily Walgreens Specialty Pharmacy.

Onboarding steps:

  1. Your doctor sends the prescription to Walgreens Specialty
  2. Walgreens contacts you to set up delivery
  3. Prior authorization must be approved before first shipment
  4. Coordinate with your clinic for any required lab monitoring

Contact information:

Support Lines and Contact Information

Member Support

BCBS Michigan Customer Service:

  • Blue Cross Blue Shield of Michigan: 1-855-811-2223
  • Blue Care Network: 1-844-642-9087
  • Hours: Monday-Friday, 8 a.m. to 6 p.m.

Provider Support:

  • Prior authorization questions: 1-877-241-2583
  • Urgent requests: Same-day processing available

What to Ask When Calling

For members:

  • "What's the status of my Orladeyo prior authorization?"
  • "What specific documentation is missing?"
  • "Can I request an expedited review?"

For providers:

  • "What are the current PA criteria for berotralstat?"
  • "Is a peer-to-peer review available for this denial?"
  • "What appeal level should we file next?"

Michigan Appeals and External Review Process

Internal Appeals with BCBS Michigan

If your initial prior authorization is denied, you have 180 days to file an internal appeal.

How to file:

  • Phone: 1-877-241-2583
  • Written: Blue Cross Blue Shield of Michigan, 600 E. Lafayette Blvd, Mail Code 2004, Detroit, Michigan 48226-2998
  • Online: BCBS Michigan member portal

Timeline: BCBS Michigan must respond within 60 calendar days of receiving your written appeal.

Michigan DIFS External Review

If BCBS Michigan upholds the denial after internal appeal, you can request an external review through the Michigan Department of Insurance and Financial Services (DIFS).

Key details:

  • Filing deadline: 127 days from final internal denial
  • Review timeline: 60 days maximum (often faster)
  • Expedited review: 72 hours for urgent cases

How to file:

Important: Michigan's 127-day external review deadline is longer than the federal 120-day standard, giving patients extra time to file.

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn Required Documentation
Insufficient HAE diagnosis Submit complete diagnostic workup C1-INH levels, genetic testing, specialist evaluation
Age under 12 years Confirm patient meets FDA age requirement Birth certificate, current age verification
Concurrent prophylaxis use Discontinue other HAE prophylaxis Letter confirming cessation of Takhzyro/Haegarda
Lack of specialist involvement Obtain HAE specialist evaluation Immunologist or allergist consultation notes
Inadequate attack documentation Provide detailed attack history Attack diary, emergency room visits, prior treatments

Scripts for Common Situations

Peer-to-peer request script for providers: "I'm requesting a peer-to-peer review for my HAE patient who needs Orladeyo prophylaxis. They've had X attacks per month despite on-demand therapy, and injectable options aren't suitable due to [specific contraindication]. Can we schedule a clinical discussion?"

Patient follow-up script: "I'm calling about my Orladeyo prior authorization submitted on [date]. Can you tell me the current status and if any additional information is needed? My member ID is [number]."

Costs and Patient Assistance Programs

Financial Support Options

Manufacturer assistance: BioCryst Pharmaceuticals offers patient support programs. Contact their patient assistance program directly for eligibility requirements and application process.

Estimated costs:

  • Wholesale Acquisition Cost (WAC): $44,484 per 28-day pack (2025)
  • Patient responsibility varies significantly based on insurance coverage and assistance programs

Additional resources:

  • National Organization for Rare Disorders (NORD) assistance programs
  • HealthWell Foundation grants for HAE patients
  • State pharmaceutical assistance programs (verify Michigan-specific options)
Note: Most patients with commercial insurance and manufacturer assistance pay significantly less than the WAC price.

When to Escalate to State Regulators

Michigan DIFS Consumer Protection

If you experience unreasonable delays or process violations, contact Michigan DIFS consumer protection:

Contact information:

  • Phone: 1-877-999-6442
  • Online complaint: Michigan DIFS website
  • Consumer brochure: "How to Appeal a Health Insurance Decision" available on DIFS website

When to escalate:

  • BCBS Michigan exceeds response timeframes
  • Repeated requests for the same documentation
  • Denial without clear medical rationale
  • Process violations during appeals

Frequently Asked Questions

How long does BCBS Michigan prior authorization take for Orladeyo? Standard requests take 5-7 business days, urgent requests 24-48 hours. Electronic submission through the provider portal typically processes fastest.

What if Orladeyo isn't on my BCBS Michigan formulary? You can request a formulary exception through the same prior authorization process. Include documentation showing medical necessity and why formulary alternatives aren't appropriate.

Can I request an expedited appeal in Michigan? Yes, Michigan offers expedited external appeals decided within 72 hours if delays would seriously jeopardize your health. Requires physician documentation of urgency.

Does step therapy apply to HAE medications? BCBS Michigan may require trials of other HAE prophylaxis medications first. Document any contraindications or previous failures with alternative therapies.

What happens after Michigan DIFS external review? DIFS decisions are binding on BCBS Michigan. If approved, your insurer must provide coverage as directed. If denied, you have 60 days to seek judicial review in Michigan circuit court.

How do I transfer my prescription to BCBS Michigan's specialty pharmacy? Contact Walgreens Specialty Pharmacy at 1-866-515-1355. They'll coordinate the transfer and handle prior authorization requirements with your doctor.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating evidence-backed, payer-specific rebuttal letters. The platform analyzes denial reasons and drafts targeted appeals using FDA labeling, peer-reviewed studies, and plan-specific criteria to improve approval rates for complex medications like Orladeyo.

Whether you're navigating your first Orladeyo prior authorization or appealing a denial, having the right documentation and understanding BCBS Michigan's specific requirements significantly improves your chances of approval. Counterforce Health's automated appeal system can help create compelling, evidence-based letters that address payer concerns while meeting procedural requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance plan directly for coverage determinations. For additional help with insurance appeals in Michigan, contact DIFS at 1-877-999-6442.

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