By Counterforce Health Team in Revcovi (elapegademase) —

How to Get Revcovi (Elapegademase) Covered by Blue Cross Blue Shield in Virginia: Complete Prior Authorization & Appeals Guide

Quick Answer: Getting Revcovi Covered in Virginia

Blue Cross Blue Shield (BCBS) in Virginia requires prior authorization for Revcovi (elapegademase) under medical benefit criteria for ADA-SCID treatment. The fastest path to approval: (1) Confirm your diagnosis with ICD-10 code D81.31 and ADA enzyme levels <1%, (2) Submit PA request through Anthem's provider portal with genetic testing results and specialist documentation, (3) If denied, file internal appeal within 180 days, then external review with Virginia's Bureau of Insurance within 120 days. Start today by verifying your plan type at anthem.com/provider and gathering your ADA-SCID diagnostic labs.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Plan Verification
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Tracking
  6. Typical Approval Timelines
  7. If You're Asked for More Information
  8. If Your Request is Denied
  9. Renewal and Re-Authorization
  10. Quick Reference Checklist

What This Guide Covers

This guide helps Virginia patients and their healthcare providers navigate Blue Cross Blue Shield's prior authorization process for Revcovi (elapegademase), an FDA-approved enzyme replacement therapy for adenosine deaminase severe combined immunodeficiency (ADA-SCID).

Who this helps:

  • Patients with confirmed ADA-SCID diagnosis needing Revcovi coverage
  • Healthcare providers submitting PA requests to Anthem Blue Cross Blue Shield Virginia
  • Families facing insurance denials for this life-saving treatment

At approximately $11,851 per 1.5 mL vial, Revcovi requires careful documentation to demonstrate medical necessity and secure coverage through Virginia's insurance landscape.

Before You Start: Plan Verification

Confirm Your Blue Cross Blue Shield Plan Type

Step 1: Check your insurance card for plan details. Anthem Blue Cross Blue Shield holds about 43% of Virginia's commercial market share.

Step 2: Verify coverage through the Anthem provider portal or call member services at the number on your card.

Step 3: Determine benefit type:

  • Medical benefit: Most likely for Revcovi (injectable/infused therapies)
  • Pharmacy benefit: Less common for specialty biologics like Revcovi

Check Formulary Status

Coverage Element What to Verify Where to Find It
Prior authorization required Yes (confirmed for Revcovi) Anthem Clinical Criteria
Formulary tier Specialty/Non-formulary Member portal or formulary document
Step therapy May require trial of alternatives PA criteria document
Quantity limits Dosing restrictions Clinical criteria guidelines
Note: Anthem updates clinical criteria quarterly. The most recent updates were effective July 1, 2024, with additional changes October 1, 2024, and January 1, 2025.

Gather Required Documentation

Essential Clinical Documentation

Diagnosis Requirements:

  • ICD-10 code: D81.31 (Severe combined immunodeficiency due to adenosine deaminase deficiency)
  • Genetic testing: Biallelic ADA gene mutations confirmed
  • Laboratory evidence: ADA enzyme activity <1% of normal levels
  • Immunological studies: T-cell and B-cell counts demonstrating SCID pattern

Prior Treatment History:

  • Documentation of previous therapies (if any)
  • Contraindications to hematopoietic stem cell transplantation
  • Response to historical pegademase (Adagen) if previously used
  • Intolerance or failure of supportive care measures

Required Forms and Submissions

For Healthcare Providers:

  1. Anthem prior authorization form (access via provider portal)
  2. Detailed medical necessity letter
  3. Recent laboratory results (within 3 months)
  4. Genetic testing reports
  5. Specialist consultation notes

For Patients:

  • Insurance card copy
  • Photo identification
  • Signed medical records release forms
Tip: Counterforce Health specializes in turning insurance denials into evidence-backed appeals for specialty medications like Revcovi, helping streamline the documentation process for both patients and providers.

Submit Your Prior Authorization Request

Submission Methods

Primary: Anthem Provider Portal

  • Log in to your provider account
  • Navigate to "Prior Authorization" section
  • Upload all required documents
  • Submit electronically for fastest processing

Alternative: Fax submission (verify current fax number through provider portal)

Clean Request Packet Checklist

✓ Completed PA form with all fields filled ✓ Medical necessity letter addressing ADA-SCID diagnosis ✓ Laboratory results showing ADA deficiency ✓ Genetic testing confirming biallelic ADA mutations ✓ Specialist notes from immunologist or geneticist ✓ Treatment plan with dosing rationale ✓ Prior therapy documentation (if applicable)

Specialty Pharmacy Coordination

Many Virginia patients receive Revcovi through specialty pharmacies like CarelonRx (for Anthem plans). Coordinate with your specialty pharmacy to ensure they're prepared for PA approval and can handle the required cold-chain storage.

Follow-Up and Tracking

When to Call

  • Day 3: Confirm receipt of submission
  • Day 10: Check processing status
  • Day 20: Request status update if no response

Sample Call Script

"Hello, I'm calling to check on a prior authorization request for Revcovi (elapegademase) submitted on [date]. The patient is [name], member ID [number], and the PA reference number is [if available]. This is for treatment of ADA-SCID, a life-threatening immunodeficiency. Can you provide a status update and expected decision timeline?"

Document Everything

  • Reference numbers for all calls
  • Names of representatives spoken with
  • Dates and times of conversations
  • Follow-up commitments made

Typical Approval Timelines

Virginia Regulatory Requirements

Request Type Timeline Notes
Standard PA 15 business days Commercial plans under Virginia law
Expedited PA 72 hours When delay could jeopardize health
Medicaid PA 14 calendar days If applicable to your plan

What Speeds Decisions

  • Complete documentation on first submission
  • Clear medical necessity rationale
  • Specialist support letters
  • Urgent clinical need documentation

What Slows Decisions

  • Missing genetic testing results
  • Incomplete prior therapy documentation
  • Unclear dosing rationale
  • Administrative errors in submission

If You're Asked for More Information

Common Information Requests

Medical Necessity Questions:

  • Provide FDA labeling showing Revcovi's approval for ADA-SCID
  • Submit peer-reviewed literature on ADA-SCID treatment
  • Include specialist society guidelines supporting enzyme replacement

Clinical Details:

  • Weight-based dosing calculations
  • Monitoring plan for immune reconstitution
  • Site of care justification (home vs. clinic administration)

Literature Support

Key sources to reference:

  • FDA prescribing information for Revcovi
  • Primary immunodeficiency treatment guidelines
  • Published clinical trial data on elapegademase efficacy

If Your Request is Denied

Internal Appeals Process

Timeline: File within 180 days of denial notice

Required Documents:

  • Original denial letter
  • Additional clinical evidence
  • Updated medical necessity letter
  • Peer-reviewed literature supporting treatment

Peer-to-Peer Review

Request a clinical discussion between your prescribing physician and Anthem's medical director. This often resolves denials when clinical rationale is clearly explained.

Virginia External Review Process

If internal appeals fail, Virginia offers independent external review through the State Corporation Commission Bureau of Insurance.

Key Details:

  • Deadline: 120 days after final internal denial
  • Form: SCC Form 216-A (External Review Request)
  • Cost: Free to consumers
  • Timeline: 45 days standard, 72 hours expedited
  • Contact: 1-877-310-6560

Success Rate: External reviews overturn approximately 40-50% of denials nationally when proper documentation is provided.

From our advocates: We've seen ADA-SCID cases succeed in external review when families include a compelling narrative about the patient's medical history alongside the clinical documentation. The independent reviewers often appreciate the human context that helps them understand why this specific treatment is essential. While outcomes vary, thorough preparation significantly improves chances of reversal.

Renewal and Re-Authorization

Calendar Your Renewal

Most PA approvals for Revcovi last 6-12 months. Set calendar reminders 60 days before expiration to begin renewal process.

Renewal Documentation

  • Updated laboratory results
  • Treatment response documentation
  • Continued medical necessity
  • Any changes in clinical status
  • Adverse event reports (if applicable)

Evidence of Treatment Success

Document immune system improvements, reduced infections, growth parameters, and quality of life measures to support continued coverage.

Quick Reference Checklist

Before Starting

□ Verify Anthem BCBS Virginia coverage □ Confirm medical vs. pharmacy benefit □ Check formulary status

Documentation Needed

□ ICD-10 D81.31 diagnosis □ ADA enzyme levels <1% □ Genetic testing results □ Specialist consultation notes □ Prior therapy records

Submission

□ Complete PA form via provider portal □ Include all supporting documents □ Coordinate with specialty pharmacy □ Document submission details

Follow-Up

□ Confirm receipt within 3 days □ Check status at 10 days □ Request updates at 20 days □ Prepare for potential peer-to-peer

If Denied

□ File internal appeal within 180 days □ Request peer-to-peer review □ Consider external review (120-day deadline) □ Contact Virginia Bureau of Insurance if needed

Frequently Asked Questions

How long does Anthem BCBS PA take in Virginia? Standard prior authorizations must be processed within 15 business days under Virginia law. Expedited requests (when delay could harm health) must be decided within 72 hours.

What if Revcovi is non-formulary on my plan? Non-formulary medications can still be covered through medical necessity exceptions. Provide strong clinical documentation showing why Revcovi is specifically needed over formulary alternatives.

Can I request an expedited appeal? Yes, if your physician certifies that delay in treatment would seriously jeopardize your health. Use Form 216-C for Virginia external reviews.

Does step therapy apply if I've failed treatments outside Virginia? Prior therapy documentation from other states is generally accepted. Provide complete records showing treatment trials, outcomes, and reasons for discontinuation.

What support is available for Revcovi costs? Contact Chiesi Total Care for manufacturer support programs and copay assistance options.

Who can help with appeals in Virginia? The Virginia Managed Care Ombudsman (1-877-310-6560) assists with health insurance appeals. Counterforce Health specializes in evidence-based appeal letters for specialty medications.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and should not be considered medical or legal advice. Always consult with your healthcare provider about treatment decisions and contact your insurance plan directly for specific coverage questions. Insurance policies and procedures may change; verify current requirements with your plan and Virginia regulatory authorities.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed rebuttals. The platform analyzes denial letters and plan policies to draft point-by-point appeals that align with payer requirements, pulling the right clinical evidence and regulatory citations to support medical necessity arguments.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.