By Counterforce Health Team in Tagrisso (osimertinib) —

How to Get Tagrisso (Osimertinib) Covered by Blue Cross Blue Shield in New York: Appeals Guide and State Protections

Answer Box: Getting Tagrisso Covered by Blue Cross Blue Shield in New York

Blue Cross Blue Shield requires prior authorization for Tagrisso (osimertinib) in New York. To get approved: (1) Confirm EGFR mutation testing shows qualifying mutations (exon 19 deletion, L858R, T790M), (2) Have your oncologist submit PA request with pathology reports and NCCN guideline alignment, (3) If denied, file internal appeal within 180 days, then external review with NY Department of Financial Services within 4 months. New York's strong patient protections include 72-hour expedited appeals for cancer drugs and binding external review decisions.

Start today: Call Blue Cross Blue Shield member services to request prior authorization forms and confirm your plan's specific requirements.

Table of Contents

Why New York State Rules Matter

New York has some of the strongest insurance patient protections in the country, especially for cancer treatments like Tagrisso. These state laws work alongside Blue Cross Blue Shield's own policies to create additional safeguards and appeal rights that don't exist in many other states.

Key New York advantages:

  • 72-hour expedited appeals for cancer drugs when delay could harm your health
  • Binding external review through the Department of Financial Services
  • Step therapy override protections that prevent insurers from requiring you to fail multiple drugs
  • Continuity of care laws that protect ongoing cancer treatment during insurance disputes

Understanding these rights can make the difference between a quick approval and months of delays.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before coverage Blue Cross Blue Shield member portal Excellus BCBS PA List
EGFR Testing Must show qualifying mutations Pathology report from FDA-approved test FDA Companion Diagnostics
Oncology Specialist Must be prescribed by cancer doctor Provider directory Blue Cross Blue Shield website
Internal Appeal Deadline 180 days from denial Denial letter NY Insurance Law
External Appeal Deadline 4 months from final denial NY DFS portal NY DFS External Appeals

Prior Authorization Requirements

Blue Cross Blue Shield follows NCCN guidelines and FDA labeling for Tagrisso approvals. Based on comparable BCBS plans, expect these requirements:

Clinical Criteria:

  • Confirmed non-small cell lung cancer (NSCLC) diagnosis
  • Positive EGFR mutation testing showing:
    • Exon 19 deletion
    • Exon 21 L858R mutation
    • S768I, L861Q, or G719X mutations
    • T790M resistance mutation (for second-line use)
  • Appropriate disease stage (metastatic, locally advanced, or adjuvant post-resection)
  • ECOG performance status 0-2

Required Documentation:

  • Pathology report with EGFR mutation results
  • TNM staging information
  • Previous treatment history (if applicable)
  • Prescriber attestation of medical necessity
Note: EGFR testing must use an FDA-approved companion diagnostic. Your oncologist's lab should automatically use approved tests, but confirm this when requesting testing.

Step-by-Step: Fastest Path to Approval

  1. Confirm EGFR Testing (Patient/Oncologist)
    • Ensure mutation testing is complete with FDA-approved method
    • Request copy of pathology report showing qualifying mutations
    • Timeline: Usually available within 7-10 business days
  2. Submit Prior Authorization (Oncologist's Office)
    • Log into Blue Cross Blue Shield provider portal
    • Complete PA form with clinical documentation
    • Include pathology report and treatment rationale
    • Timeline: Submit electronically for fastest processing
  3. Track Your Request (Patient)
    • Call Blue Cross Blue Shield member services for status updates
    • Reference your PA tracking number
    • Timeline: Standard review takes 30-45 days
  4. Request Expedited Review if Urgent (Oncologist)
    • Submit physician attestation that delay risks patient health
    • Emphasize cancer progression or symptom severity
    • Timeline: Decision within 72 hours under NY law
  5. Prepare for Possible Denial (Patient/Oncologist)
    • Gather additional clinical evidence
    • Review denial letter carefully for specific reasons
    • Timeline: Begin appeal preparation immediately
  6. File Internal Appeal if Denied (Patient/Representative)
    • Submit within 180 days of denial notice
    • Include additional medical evidence and peer-reviewed studies
    • Timeline: 30 days for standard, 72 hours for expedited
  7. Escalate to External Review (Patient/Representative)
    • File with NY Department of Financial Services within 4 months
    • Include all documentation from internal appeal
    • Timeline: 30 days for decision (binding on insurer)

New York Step Therapy Protections

New York Insurance Law §4903 provides strong protections against excessive step therapy requirements. Effective January 1, 2026, enhanced rules make it even easier to get step therapy overrides.

Automatic Override Situations:

  • You've already tried the required step drug and it failed or caused harm
  • The step drug lacks FDA approval for your specific condition
  • You're stable on Tagrisso and switching would not be in your best interest
  • The step drug would likely cause harm based on your medical history

Key Protections:

  • No more than 2 step drugs can be required for the same condition
  • No repeat stepping if you've already tried and failed a drug within the past 365 days
  • 30-day maximum trial period for preferred alternatives
  • Prescriber attestation is sufficient evidence for override (effective 2026)
Tip: If Blue Cross Blue Shield requires step therapy, ask your oncologist to document any previous EGFR inhibitor failures, even from other states or insurance plans. This can qualify you for an immediate override.

Continuity of Care During Transitions

New York's proposed Continuity of Cancer Care Act (COCCA) would protect patients during insurance network changes. While not yet enacted, current Blue Cross Blue Shield policies already provide some protections:

Current Protections:

  • 60-day continuation for hospital services during contract disputes
  • Continuity of care requests for ongoing cancer treatment
  • Coverage extensions while appeals are pending

How to Request Continuity:

  1. Contact Blue Cross Blue Shield member services immediately when you learn of network changes
  2. Submit continuity of care form with documentation of ongoing treatment
  3. Include letter from oncologist explaining medical necessity of continuing current care
  4. Reference your cancer diagnosis and active treatment protocol

Community Health Advocates at 888-614-5400 can help you navigate continuity of care requests at no cost.

Appeals Process: Internal to External Review

Internal Appeals

Timeline: File within 180 days of denial Decision: 30 days standard, 72 hours expedited Required: Denial letter, additional medical evidence, prescriber support

What to Include:

  • Copy of original denial letter
  • Letter from oncologist explaining medical necessity
  • Peer-reviewed studies supporting Tagrisso use
  • Documentation of failed alternative therapies
  • Patient's treatment history and current condition

External Review

Timeline: File within 4 months of final internal denial Decision: 30 days standard, 72 hours urgent (binding) Cost: $25 fee (waived for financial hardship or Medicaid)

How to File:

  1. Complete NY DFS External Appeal Application
  2. Submit online via DFS Portal (preferred method)
  3. Include Comprehensive Physician Attestation Form
  4. Attach all medical records and internal appeal documentation
Important: External review decisions are binding on Blue Cross Blue Shield. If approved, they must cover your treatment and reimburse the filing fee.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
No EGFR mutation documented Submit pathology report showing qualifying mutations FDA-approved test results, lab report
Not medically necessary Provide clinical evidence and guidelines NCCN guidelines, peer-reviewed studies
Step therapy required Request override based on NY law Prior therapy failures, contraindications
Wrong disease stage Clarify staging and indication TNM staging, treatment protocol
Quantity limits exceeded Justify dosing based on patient factors Weight-based calculations, FDA labeling

Scripts for Calling Blue Cross Blue Shield

For Prior Authorization Status

"Hi, I'm calling to check the status of a prior authorization request for Tagrisso, also called osimertinib. My member ID is [number] and the PA was submitted by Dr. [name] on [date]. Can you tell me the current status and expected timeline? If there are any missing documents, I'd like to know what's needed and how to submit them."

For Expedited Review

"I need to request an expedited review for a Tagrisso prior authorization. My oncologist has indicated that any delay in starting this cancer treatment could seriously impact my health. Under New York law, cancer drug appeals should be decided within 72 hours when medically urgent. How do I submit the physician attestation for expedited review?"

For Step Therapy Override

"I'm requesting a step therapy override for Tagrisso under New York Insurance Law section 4903. I have documentation showing that [the required step drug would be harmful/I've already failed this drug/I'm stable on current therapy]. My doctor is prepared to provide written attestation. What's the process for submitting this override request?"

When to Escalate to State Regulators

Contact the New York Department of Financial Services if:

  • Blue Cross Blue Shield misses legal deadlines (72 hours expedited, 30 days standard)
  • Your appeal is denied without proper medical review
  • The insurer fails to follow New York step therapy protections
  • You experience discrimination or unfair treatment

Contact Information:

Include your member ID, denial letters, appeal documentation, and a clear timeline of events.

Cost Assistance and Patient Support

While working through insurance approval, explore these cost assistance options:

AstraZeneca Patient Support:

  • AZ&Me Prescription Savings Program
  • May provide free medication for eligible patients
  • Income-based assistance available

Foundation Grants:

  • Patient Advocate Foundation
  • CancerCare Financial Assistance
  • Leukemia & Lymphoma Society (for blood cancers)

State Programs:

  • New York State of Health premium tax credits
  • Medicaid expansion coverage
  • Essential Plan for moderate-income residents
From our advocates: "We've seen patients successfully get Tagrisso covered after initial denials by gathering comprehensive documentation of EGFR testing and prior treatment failures. The key is persistence and using New York's strong appeal protections. One patient's external review was approved within the 30-day timeline after Blue Cross Blue Shield initially denied coverage, citing the clinical evidence and NCCN guidelines in the appeal."

FAQ

Q: How long does Blue Cross Blue Shield prior authorization take in New York? A: Standard review takes 30-45 days. Expedited review (when medically urgent) must be completed within 72 hours under New York law.

Q: What if Tagrisso is not on my Blue Cross Blue Shield formulary? A: You can request a formulary exception by having your oncologist submit documentation showing medical necessity and lack of suitable alternatives on the formulary.

Q: Can I get an expedited appeal for cancer treatment? A: Yes. New York law requires 72-hour decisions for expedited appeals when delay could seriously impact your health. Your oncologist must provide written attestation of urgency.

Q: Does step therapy apply if I failed similar drugs outside of New York? A: No. New York law prohibits requiring you to repeat step therapy if you've already tried and failed the required drug within the past 365 days, regardless of where the trial occurred.

Q: What happens if my external appeal is approved? A: Blue Cross Blue Shield must cover your Tagrisso treatment and reimburse your $25 filing fee. The decision is binding and cannot be overturned by the insurer.

Q: Can I continue current treatment while my appeal is pending? A: You may be able to request continuity of care coverage. Contact Blue Cross Blue Shield member services and consider working with Community Health Advocates for assistance.

Q: What if I'm on Medicare Advantage through Blue Cross Blue Shield? A: Medicare Advantage plans have different appeal processes. You can appeal to the plan first, then to an Independent Review Entity, and finally to an Administrative Law Judge if needed.

Q: How do I get help with my appeal if I can't afford a lawyer? A: Community Health Advocates provides free assistance to all New Yorkers at 888-614-5400. They can help you understand your rights and prepare appeal documentation.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters and payer policies to create targeted, evidence-backed appeals that align with each plan's specific requirements. For complex cases like Tagrisso coverage, we help identify the exact clinical documentation needed and draft point-by-point rebuttals that address payer concerns while highlighting patient protections under state law.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on your specific plan terms and medical circumstances. Always consult with your healthcare provider and insurance company for guidance specific to your situation. Coverage policies and state laws may change; verify current requirements with official sources.

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