By Counterforce Health Team in Pemazyre (pemigatinib) —

How to Get Pemazyre (Pemigatinib) Covered by Blue Cross Blue Shield in Ohio: Prior Authorization, Appeals & Step Therapy Override Guide

Answer Box: Getting Pemazyre Covered by BCBS Ohio

Pemazyre (pemigatinib) is covered by Blue Cross Blue Shield Ohio but requires prior authorization with documented FGFR2 fusion/rearrangement testing and ophthalmology monitoring plan. Fastest path to approval: Submit PA with biomarker report, treatment history, and baseline eye exam documentation. Start today: Contact BCBS Ohio Pharmacy Services at 1-800-686-1526 to verify formulary tier and obtain PA forms. Appeals available through Ohio's external review process within 180 days of denial.

Table of Contents

  1. BCBS Ohio Plan Types & Coverage Implications
  2. Pemazyre Formulary Status & Tier Placement
  3. Prior Authorization Requirements & Common Denials
  4. Step Therapy & Override Pathways
  5. Specialty Pharmacy Network & Patient Setup
  6. Appeals Process: Internal to External Review
  7. Cost-Share Basics & Patient Assistance
  8. Submission Mechanics: Forms & Portals
  9. Common Approval Patterns
  10. FAQ: Ohio-Specific Questions

BCBS Ohio Plan Types & Coverage Implications

Blue Cross Blue Shield Ohio operates as Anthem, offering multiple plan types that affect Pemazyre coverage:

Commercial Plans (Employer & Individual)

  • HMO plans require referrals to oncologists and ophthalmologists
  • PPO plans allow direct specialist access but may have higher out-of-network costs
  • All plans require prior authorization for specialty oncology drugs

Medicare Advantage

Medicaid (Buckeye Health Plan)

  • Managed through Ohio Medicaid's preferred drug list
  • Appeals go through Ohio Department of Medicaid for state fair hearings

Pemazyre Formulary Status & Tier Placement

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all indications BCBS Ohio formulary Anthem OH Drug List
Formulary Tier Specialty tier (typically Tier 4-5) Plan documents Anthem Formulary Navigator
Step Therapy May apply for off-label use PA criteria Provider News Updates
Quantity Limits 30-day supply typical Pharmacy benefits Plan formulary
Site of Care Specialty pharmacy required Designated network Anthem Specialty Network

Formulary Status: Pemazyre appears on BCBS Ohio's 2024 formulary but with prior authorization requirements. The drug is classified as a specialty medication, placing it on higher cost-sharing tiers.

Alternative Coverage Options: If denied, consider formulary exception requests or appeals to external review through the Ohio Department of Insurance.

Prior Authorization Requirements & Common Denials

Medical Necessity Criteria

Required Documentation:

  1. Biomarker Testing: FDA-approved FGFR2 fusion/rearrangement test results
  2. Diagnosis Confirmation: Unresectable/metastatic cholangiocarcinoma or relapsed/refractory myeloid/lymphoid neoplasms
  3. Treatment History: Documentation of previous therapies (for "previously treated" indication)
  4. Ophthalmology Plan: Baseline eye exam with OCT and monitoring schedule

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
No FGFR alteration documented Submit companion diagnostic test FDA-approved biomarker report
Off-label use without step therapy Request step therapy override Medical necessity letter citing contraindications
Missing ophthalmology monitoring Establish monitoring plan Baseline OCT + follow-up schedule
Insufficient treatment history Document prior therapies Medical records showing failed treatments

Clinician Corner: Medical Necessity Letter Checklist

For Prescribers: Your medical necessity letter should include:Patient's specific FGFR2 alteration type and testing methodPrior treatment failures with standard therapies (gemcitabine/cisplatin for CCA)Contraindications to alternative treatmentsEstablished ophthalmology monitoring plan per FDA labeling requirementsClinical rationale citing NCCN guidelines or FDA approval basis

Step Therapy & Override Pathways

Ohio Step Therapy Law: Ohio Revised Code 3901.832 allows step therapy exemptions when:

  • Patient has tried and failed the preferred drug
  • Preferred drug is contraindicated
  • Patient is stable on current therapy

Step Therapy Override Process

  1. Clinical Exception Request: Submit documentation of contraindications or prior failures
  2. Stability Argument: If switching from effective therapy would be detrimental
  3. Medical History Review: Prior treatment attempts from any state count toward step therapy requirements

For Cholangiocarcinoma: First-line treatments typically include gemcitabine-based chemotherapy. FGFR2+ patients may qualify for direct Pemazyre access due to targeted indication.

Specialty Pharmacy Network & Patient Setup

BCBS Ohio Designated Specialty Pharmacies:

Patient Enrollment Steps

  1. Verify Network: Confirm your plan's designated specialty pharmacy partners
  2. Transfer Prescription: Provider sends prescription to designated pharmacy
  3. Patient Enrollment: Complete intake forms and insurance verification
  4. Coordination of Benefits: Specialty pharmacy handles PA submission if not already completed
  5. Delivery Setup: Arrange home delivery or pickup scheduling

Monitoring Requirements: Specialty pharmacies coordinate with prescribers for required ophthalmology monitoring and dose adjustments.

Appeals Process: Internal to External Review

Timeline & Deadlines

Internal Appeals:

  • First Level: 60 days to file, 15 days for decision (72 hours if urgent)
  • Second Level: 60 days to file after first-level denial

External Review:

  • Filing Deadline: 180 days from final internal denial
  • Decision Timeline: 30 days standard, 72 hours expedited
  • Contact: Ohio Department of Insurance at 1-800-686-1526

Appeals Playbook for BCBS Ohio

Level 1: Internal Appeal

  • Submit via BCBS Ohio member portal or member services
  • Include: Denial letter, medical records, prescriber letter, biomarker testing
  • Request expedited review if treatment delay endangers health

Level 2: Second Internal Appeal

  • Available if first appeal denied
  • Same documentation standards
  • Final internal step before external review

External Review (IRO)

When to Request Expedited Review

Request expedited appeals when:

  • Disease progression would occur during standard timeline
  • Current treatment is failing
  • Delay would seriously jeopardize health or ability to regain maximum function

Cost-Share Basics & Patient Assistance

Typical Cost Structure:

  • Specialty tier copay/coinsurance applies
  • May be subject to deductible
  • Out-of-pocket maximums provide annual cap

Patient Assistance Options:

  • Incyte Patient Assistance: Contact manufacturer for copay support programs
  • Foundation Grants: CancerCare, Patient Advocate Foundation, Leukemia & Lymphoma Society
  • State Programs: Ohio pharmaceutical assistance programs for eligible residents
Note: This information is educational only. Consult your plan documents for specific cost-sharing details.

Submission Mechanics: Forms & Portals

Required Forms & Submission Methods

Prior Authorization:

  • Submit through BCBS Ohio provider portal or fax (verify current contact with member services)
  • Include completed PA form, medical necessity letter, and supporting documentation
  • Allow 15 business days for standard review

Key Fields That Matter:

  • Specific FGFR alteration type and testing method
  • Previous treatment attempts and outcomes
  • Ophthalmology monitoring plan details
  • ICD-10 codes: C22.1 (intrahepatic cholangiocarcinoma), C24.0 (extrahepatic cholangiocarcinoma)

Common Approval Patterns

Strong Submissions Include:

  1. Clear Biomarker Evidence: FDA-approved companion diagnostic results
  2. Treatment History: Documented progression on or intolerance to standard therapies
  3. Monitoring Compliance: Established ophthalmology care plan
  4. Clinical Rationale: Evidence-based medical necessity argument
  5. Guideline Support: References to NCCN, FDA labeling, or peer-reviewed literature

Success Factors:

  • Complete documentation on first submission
  • Clear communication of medical necessity
  • Compliance with monitoring requirements
  • Appropriate ICD-10 and diagnostic coding

FAQ: Ohio-Specific Questions

Q: How long does BCBS Ohio prior authorization take? A: Standard PA decisions within 15 business days; expedited reviews within 72 hours for urgent cases.

Q: What if Pemazyre is non-formulary on my plan? A: Request a formulary exception with medical necessity documentation. If denied, appeal through Ohio's external review process.

Q: Can I request expedited appeal in Ohio? A: Yes, if treatment delay would seriously endanger your health. Both internal and external expedited reviews are available.

Q: Does step therapy apply if I failed treatments outside Ohio? A: Yes, Ohio law recognizes prior treatment attempts from any state when evaluating step therapy requirements.

Q: Who pays for external review in Ohio? A: External review through Ohio Department of Insurance is free to patients.

Q: What happens if the IRO approves my appeal? A: The decision is binding on BCBS Ohio - they must cover Pemazyre for the duration of your prescription including refills.

From Our Advocates

We've seen cases where patients initially received denials for missing ophthalmology documentation, but approvals came quickly once baseline OCT results and monitoring plans were submitted. The key is having your oncologist and ophthalmologist coordinate before the PA submission - this prevents delays and demonstrates compliance with safety monitoring requirements.

Getting prescription drug denials overturned requires strategic documentation and understanding payer-specific requirements. Counterforce Health helps patients, clinicians, and specialty pharmacies transform insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to each plan's own rules.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan details and clinical circumstances. Always consult your healthcare provider and insurance plan documents for specific guidance. For additional help with Ohio health insurance appeals, contact the Ohio Department of Insurance Consumer Services at 1-800-686-1526.

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