By Counterforce Health Team in Takhzyro (lanadelumab-flyo) —

How to Get Takhzyro (Lanadelumab) Covered by Blue Cross Blue Shield in New York: Complete Forms Guide

Answer Box: Getting Takhzyro Covered in New York

To get Takhzyro (lanadelumab-flyo) covered by Blue Cross Blue Shield in New York: Submit prior authorization through the Availity portal with confirmed HAE diagnosis (C1-INH/C4 labs), attack history documentation, and specialist prescription. If denied, file an internal appeal within plan deadlines, then request external review through NY Department of Financial Services within 4 months. Start today: Log into your BCBS member portal to verify your specific plan's formulary status and download the current PA form.

Table of Contents

  1. Start Here: Verify Your Plan
  2. Prior Authorization Forms
  3. Submission Portals and Methods
  4. Specialty Pharmacy Requirements
  5. Appeals Process
  6. Support and Contact Information
  7. New York State Resources
  8. Cost Assistance Programs

Start Here: Verify Your Plan

Before starting any paperwork, confirm your exact Blue Cross Blue Shield plan. New York has multiple BCBS affiliates with different coverage policies:

  • Empire BlueCross BlueShield (NYC metro area)
  • Excellus BlueCross BlueShield (Central/Western NY)
  • HealthNow New York (Western NY)
  • Anthem Blue Cross Blue Shield (various regions)

Action Steps:

  1. Check your insurance card for the specific BCBS plan name
  2. Log into your member portal to verify Takhzyro's formulary status
  3. Note your plan's pharmacy benefit manager (often Express Scripts or CVS Caremark)
Note: Each BCBS affiliate may have slightly different forms and submission processes, though all require prior authorization for Takhzyro.

Prior Authorization Forms

Required Documentation

All BCBS New York plans require prior authorization for Takhzyro with these core elements:

Clinical Documentation:

  • Confirmed diagnosis of hereditary angioedema (HAE) Type I or II
  • C4 and C1-inhibitor (functional and antigenic) lab results
  • Documentation of attack frequency and severity
  • Previous therapy trials and outcomes
  • Prescriber attestation from specialist (allergist, immunologist, or hematologist)

Key Requirements:

  • Patient must be ≥2 years old
  • No concomitant prophylactic HAE therapy
  • Evidence of inadequate response to or contraindications for alternative treatments (Haegarda, Orladeyo)

Specific Form Requirements by Plan

BCBS Plan Form Location Submission Method
Empire BCBS Provider portal Availity portal preferred
Excellus BCBS Drug policies page Provider portal or fax
HealthNow NY Provider bulletins Availity or designated fax
Anthem BCBS Prior auth page Availity portal
Tip: Always download the most current form version, as requirements update frequently. Forms older than 6 months may be rejected.

Submission Portals and Methods

Primary: Availity Portal

For all BCBS New York plans, the preferred submission method is through Availity:

  1. Register at Availity Essentials (if not already enrolled)
  2. Navigate to Patient Management → Authorizations & Referrals → Authorizations
  3. Upload all supporting documentation (clinical notes, lab results, specialist letters)
  4. Track your submission status in real-time

Contact for Availity Support: Provider Services at your specific BCBS plan

Alternative Submission Methods

Specialty Drug Fax Numbers:

  • Medical injectables/specialty drugs: 1-844-493-9206
  • Retail pharmacy: 1-844-490-4877

Phone Support:

  • Pharmacy department: 1-800-450-8753 (Mon–Fri 8 a.m.–7 p.m.; Sat 10 a.m.–2 p.m.)
Important: Electronic submission via Availity typically results in faster processing times and better tracking capabilities.

Specialty Pharmacy Requirements

Network Restrictions

Starting November 1, 2025, BCBS New York plans require Takhzyro to be dispensed through designated specialty pharmacy networks only.

Approved Specialty Pharmacies (verify current list with your plan):

  • CVS Specialty Pharmacy
  • Walgreens Specialty Pharmacy
  • Express Scripts Specialty Pharmacy
  • Accredo Specialty Pharmacy

Dispensing Limitations

  • 30-day supply limit per fill
  • Quantity restrictions based on approved dosing interval (every 2-4 weeks)
  • Prior authorization renewal required for continued therapy

Patient Action Steps:

  1. Contact your specialty pharmacy to initiate enrollment
  2. Provide insurance information and prescription
  3. Coordinate delivery scheduling
  4. Set up refill reminders aligned with your dosing schedule

Appeals Process

Internal Appeals (First Level)

If your initial prior authorization is denied:

Timeline: Must file within 60 days of denial notice

Required Documents:

  • Copy of denial letter
  • Additional clinical documentation
  • Updated medical necessity letter from prescriber
  • Any new lab results or specialist evaluations

External Appeals (New York State)

After exhausting internal appeals, you have strong rights in New York:

Eligibility: Final adverse determination from BCBS on medical necessity Deadline: 4 months from final denial (strict deadline) Cost: No fee for patients

Filing Process:

  1. Complete NY State External Appeal Application
  2. Submit by mail or fax to NY Department of Financial Services
    • Mail: 99 Washington Avenue, Box 177, Albany, NY 12210
    • Fax: (800) 332-2729

Review Timeline:

  • Standard review: 30 days
  • Expedited review: 72 hours (if physician attests to urgency)
From our advocates: In our experience helping patients with rare disease appeals, New York's external review process has a strong track record for overturning denials when proper medical evidence is submitted. The key is comprehensive documentation of HAE attacks and failed alternative therapies.

Support and Contact Information

Member Services by Plan

BCBS Plan Member Services Provider Services
Empire BCBS 1-800-EMPIRE1 Check provider portal
Excellus BCBS 1-800-724-1395 1-800-462-2583
HealthNow NY 1-800-809-8009 Check provider bulletins
Anthem BCBS 1-855-769-1467 Use Availity messaging

What to Ask When You Call

For Members:

  • "What is Takhzyro's formulary status on my specific plan?"
  • "What prior authorization requirements apply to my case?"
  • "Can you provide the current PA form and submission instructions?"
  • "What is the typical processing timeline?"

For Providers:

  • "What clinical documentation is required for Takhzyro PA?"
  • "Are there step therapy requirements for this patient?"
  • "Can we request a peer-to-peer review?"
  • "What specialty pharmacy restrictions apply?"

New York State Resources

Consumer Assistance

Community Health Advocates (CHA)

NY Department of Financial Services

New York provides some of the strongest patient appeal rights in the nation:

  • Independent medical review by certified external reviewers
  • Binding decisions on insurers when appeals are upheld
  • Expedited review for urgent medical needs
  • Searchable database of previous appeal decisions for reference

Cost Assistance Programs

Manufacturer Support

Takeda Patient Assistance

  • Takeda Help at Hand: 1-800-830-9159
  • Copay assistance for eligible commercially insured patients
  • Patient assistance program for uninsured/underinsured patients

Additional Resources

  • HealthWell Foundation: Disease-specific grants for HAE patients
  • National Organization for Rare Disorders (NORD): Patient assistance programs
  • State pharmaceutical assistance programs through NY Department of Health

When to Get Professional Help

Consider working with a coverage advocate when:

  • Multiple prior authorizations have been denied
  • You're facing complex step therapy requirements
  • External appeal deadlines are approaching
  • You need help gathering clinical evidence

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform helps patients and clinicians navigate complex prior authorization requirements by analyzing denial letters, plan policies, and clinical notes to create point-by-point rebuttals aligned with each plan's specific criteria.

Frequently Asked Questions

How long does BCBS New York PA approval take? Standard review is typically 5-10 business days through Availity portal. Expedited reviews (for urgent medical needs) are processed within 72 hours.

What if Takhzyro is non-formulary on my plan? You can request a formulary exception with medical necessity documentation. This requires demonstrating that preferred alternatives are ineffective or contraindicated.

Can I appeal if I'm denied due to step therapy? Yes. Document previous therapy failures, contraindications, or medical reasons why step therapy is inappropriate for your case.

Does living in New York give me special appeal rights? Yes. New York's external appeal process is particularly robust, with independent medical reviewers and binding decisions on insurers.

What happens if I miss the external appeal deadline? The 4-month deadline is strict and cannot be extended. However, you may still have options through state complaint processes or legal advocacy.

Update Cadence and Staying Current

Check quarterly for updates to:

  • Formulary status and tier placement
  • Prior authorization forms and requirements
  • Specialty pharmacy network changes
  • Appeals procedures and deadlines

Key resources to bookmark:

Important: Insurance requirements change frequently. Always verify current forms, deadlines, and procedures before submitting any requests.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for the most current requirements and procedures. Coverage decisions are made by your insurance plan based on your specific policy terms and medical circumstances.

Sources & Further Reading

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