How to Get Photrexa (Riboflavin) Covered by Blue Cross Blue Shield in Washington: Complete Prior Authorization and Appeals Guide
Answer Box: Getting Photrexa Covered by Blue Cross Blue Shield in Washington
Blue Cross Blue Shield plans in Washington (Premera Blue Cross and Regence BlueShield) require prior authorization for Photrexa (riboflavin ophthalmic solution) used in epithelium-off corneal cross-linking for progressive keratoconus. To get approval: (1) Document keratoconus progression with serial topography showing ≥1.0 diopter Kmax increase over 6-12 months, (2) Submit PA via your provider's Availity portal or Premera provider portal with medical necessity letter, and (3) If denied, file internal appeal within 180 days, then external review through Washington's Office of Insurance Commissioner at 1-800-562-6900.
Table of Contents
- What This Guide Covers
- Before You Start: Verify Your Plan
- Gather What You Need
- Submit the Prior Authorization Request
- Follow-Up and Timeline Management
- If You're Asked for More Information
- If Your Request is Denied
- Appeals Process in Washington
- Common Denial Reasons and Solutions
- Cost-Saving Options
- FAQ
What This Guide Covers
This comprehensive guide helps patients with progressive keratoconus and their eye care providers navigate the prior authorization process for Photrexa (riboflavin ophthalmic solution) with Blue Cross Blue Shield plans in Washington state.
Photrexa, manufactured by Glaukos, is used with the FDA-approved iLink® system for epithelium-off corneal collagen cross-linking (CXL). This treatment stabilizes the cornea by creating cross-links in the corneal stroma, helping slow or stop keratoconus progression. The procedure typically costs $2,500–$4,000 per eye, making insurance coverage crucial for most patients.
Who this helps: Patients diagnosed with progressive keratoconus, their families, ophthalmologists, optometrists, and clinic staff managing prior authorizations.
Before You Start: Verify Your Plan
Coverage at a Glance
| Requirement | What It Means | Where to Find It |
|---|---|---|
| Prior Authorization | Required for all Photrexa prescriptions | Premera PA requirements |
| Formulary Status | Check if covered and at what tier | Member portal or call customer service |
| Progressive Keratoconus | Must document worsening condition | Serial corneal topography reports |
| Epithelium-Off Protocol | Only FDA-approved method covered | Treatment must use iLink® system |
| Failed Conservative Care | Glasses/contacts tried first | Medical records showing intolerance/failure |
Confirm Your Plan Type
Washington's main Blue Cross Blue Shield plans are:
- Premera Blue Cross (largest BCBS plan in WA)
- Regence BlueShield (covers parts of WA)
Call the member services number on your insurance card to confirm:
- Whether Photrexa requires prior authorization
- Your plan's specific formulary tier for this medication
- In-network ophthalmology providers in your area
- Whether your plan covers the procedure at ambulatory surgery centers
Gather What You Need
Essential Documentation Checklist
Medical Records:
- Diagnosis confirmation with ICD-10 codes (H18.4xx for keratoconus)
- Serial corneal topography showing progression (≥1.0D Kmax increase over 6-12 months)
- Pachymetry measurements (corneal thickness ≥350 μm required)
- Visual acuity measurements and changes over time
- Documentation of failed conservative treatments (glasses, rigid contact lenses)
Clinical Documentation:
- Comprehensive eye exam notes from corneal specialist
- Photos of corneal findings if available (Fleischer ring, Vogt's striae)
- Treatment plan specifying epithelium-off CXL with iLink® system
Insurance Information:
- Current insurance card with member ID
- Prior authorization form (available through provider portal)
- Any previous denial letters or correspondence
Tip: Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. Their platform helps identify the specific denial basis and drafts point-by-point responses aligned to each plan's own rules.
Submit the Prior Authorization Request
Step-by-Step: Fastest Path to Approval
1. Provider Portal Submission (Recommended)
- Access Premera's provider portal or use Availity
- Complete prior authorization request form
- Upload all supporting documentation
- Timeline: Submit 2-3 weeks before planned procedure
2. Medical Necessity Letter Requirements Your ophthalmologist should include:
- Problem statement: Progressive keratoconus with specific Kmax values and dates
- Prior treatments: Failed spectacle correction, contact lens intolerance details
- Clinical rationale: Why CXL is medically necessary to prevent vision loss
- Treatment plan: Epithelium-off protocol using FDA-approved iLink® system
- Prognosis: Expected stabilization and vision preservation
3. Specialty Pharmacy Coordination Photrexa is distributed through Orsini Specialty Pharmacy, which can:
- Verify your BCBS benefits
- Submit prior authorization on your behalf
- Coordinate delivery 2-3 weeks before your procedure
- Handle copay assistance applications
Contact Orsini: 847-734-7373 ext. 545 or [email protected]
Follow-Up and Timeline Management
Standard Review Timelines
| Review Type | BCBS Decision Timeline | When to Follow Up |
|---|---|---|
| Standard PA | 15 business days (pre-service) | Day 10 if no response |
| Expedited PA | 72 hours | 24 hours if urgent |
| Post-service review | 30 calendar days | Day 20 if no response |
Sample Follow-Up Script
"Hi, this is [name] calling about prior authorization request #[number] for Photrexa for member [ID]. The request was submitted on [date]. Can you provide a status update and expected decision date? If additional information is needed, please let me know exactly what's required and the deadline for submission."
Document everything: Reference numbers, representative names, dates, and next steps.
If You're Asked for More Information
Insurance reviewers commonly request:
Additional Clinical Evidence:
- More detailed progression documentation
- Peer-reviewed studies supporting CXL efficacy
- Specialist consultation notes
- Patient symptom documentation
Procedural Clarifications:
- Confirmation of FDA-approved protocol use
- Site of care verification (in-network facility)
- HCPCS codes (J2787 for riboflavin)
Response Strategy:
- Respond within 10 business days of request
- Include cover letter summarizing why additional evidence supports medical necessity
- Reference specific BCBS policy criteria in your response
If Your Request is Denied
First Steps After Denial
- Review the denial letter carefully for specific reason codes
- Check if it's a "soft denial" (missing information) vs. "hard denial" (not covered)
- Contact your provider immediately to discuss appeal options
- Request peer-to-peer review if available
Clinician Corner: Medical Necessity Letter Enhancement
When appealing, strengthen your medical necessity argument with:
Clinical Guidelines References:
- American Academy of Ophthalmology Preferred Practice Pattern for corneal ectasia
- FDA labeling for Photrexa and iLink® system
- Published RCT data showing CXL efficacy in halting progression
Enhanced Documentation:
- Quantified progression rates (specific Kmax values with dates)
- Impact on daily activities and quality of life
- Risk of continued progression without intervention
- Long-term cost comparison (CXL vs. eventual corneal transplant)
Appeals Process in Washington
Washington state provides robust protections for insurance appeals, with multiple levels of review available.
Internal Appeals (Required First)
Level 1 Internal Appeal:
- Deadline: Within 180 days of denial
- Submission: Use BCBS Reconsideration Request Form
- Timeline: 30 calendar days for standard review, 72 hours for expedited
- Required: Include denial letter, additional medical evidence, and specific policy citations
How to Submit:
- Online through member portal
- Certified mail to address on denial letter
- Fax (verify current number with customer service)
External Review (After Internal Appeals)
If your internal appeal is denied, Washington law provides access to Independent Review Organization (IRO) review.
External Review Process:
- Eligibility: After final internal denial
- Deadline: Within 180 days of internal appeal denial
- Cost: Free to patient
- Contact: Washington Office of Insurance Commissioner at 1-800-562-6900
- Timeline: 20 days for standard review, 72 hours for expedited
- Binding: Decision is binding on the insurance company
The IRO consists of independent medical experts who review your case based on medical necessity and current treatment standards, not just your plan's internal policies.
Common Denial Reasons and Solutions
| Denial Reason | How to Overturn |
|---|---|
| "Experimental/Investigational" | Cite FDA approval of epithelium-off CXL; reference BCBS policies covering approved protocol |
| "Not medically necessary" | Provide serial topography showing progression; document failed conservative care |
| "Insufficient documentation" | Submit complete progression timeline with specific Kmax values and dates |
| "Non-formulary drug" | Request formulary exception with medical necessity justification |
| "Step therapy required" | Document contraindications or failures of required first-line treatments |
From Our Advocates
"We've seen many keratoconus cases where the initial denial was overturned simply by providing more complete progression documentation. Insurance reviewers need to see the specific numbers—not just 'worsening keratoconus' but 'Kmax increased from 52.3D to 54.1D over 8 months.' The more precise your documentation, the stronger your case becomes." (Composite experience from multiple cases; outcomes vary.)
Cost-Saving Options
Manufacturer Support
- Glaukos Patient Assistance: Up to $100 per eye ($200 maximum) for commercial insurance patients
- Eligibility: Commercial insurance only (excludes Medicare/Medicaid)
- How to apply: Submit EOB after procedure through Glaukos website
Additional Resources
- Check with your employer's Employee Assistance Program for health advocacy services
- Contact Counterforce Health for professional appeals assistance
- Consider timing procedure early in plan year if you have high deductibles
Frequently Asked Questions
Q: How long does Blue Cross Blue Shield PA take in Washington? A: Standard prior authorizations take up to 15 business days for pre-service requests. Expedited reviews (when medically urgent) must be completed within 72 hours.
Q: What if Photrexa is non-formulary on my plan? A: Request a formulary exception by demonstrating medical necessity and lack of suitable alternatives. Include documentation that epithelium-off CXL is the only FDA-approved method for your condition.
Q: Can I request an expedited appeal if my keratoconus is progressing rapidly? A: Yes. If rapid progression threatens your vision, request expedited review at both internal appeal and external review levels. Document the urgency with recent topography changes.
Q: Does step therapy apply if I've already failed treatments outside Washington? A: Previous treatment failures from other states should count toward step therapy requirements. Ensure your provider includes complete treatment history from all locations.
Q: What happens if I miss the appeal deadline? A: Washington allows some flexibility for "good cause" delays, but act quickly. Contact the Office of Insurance Commissioner immediately to discuss options if you've missed standard deadlines.
Q: Is epithelium-on CXL covered by BCBS? A: No. BCBS policies consistently exclude epithelium-on (transepithelial) CXL as experimental. Only FDA-approved epithelium-off protocols are covered.
Sources & Further Reading
- Premera Blue Cross Prior Authorization Requirements
- Washington Office of Insurance Commissioner Appeals Guide
- Glaukos CXL Insurance Coverage Guide
- ASCRS Cross-Linking Billing Guidelines
- Blue Cross Blue Shield Medical Policies on Corneal Cross-Linking
Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice or legal counsel. Coverage decisions vary by individual plan and medical circumstances. Always consult with your healthcare provider and insurance company for plan-specific guidance. For additional support with complex appeals, Counterforce Health offers specialized services to help patients and providers navigate insurance denials for specialty medications and procedures.
Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.