By Counterforce Health Team in Taltz (ixekizumab) —

How to Get Taltz (Ixekizumab) Covered by Blue Cross Blue Shield in Pennsylvania: Prior Authorization Guide & Appeal Scripts

Quick Answer: Getting Taltz Covered in Pennsylvania

Blue Cross Blue Shield plans in Pennsylvania require prior authorization for Taltz (ixekizumab), typically including step therapy with at least one TNF inhibitor failure. Most commercial and health exchange plans classify Taltz as non-preferred, while Medicaid managed plans may offer preferred status. The fastest path: have your provider submit a prior authorization request documenting diagnosis severity (PASI score, BSA affected), failed treatments with specific dates and reasons, and negative TB screening. If denied, you can appeal internally within 60-180 days, then request external review through Pennsylvania's new state-supervised program within 4 months.

First step today: Contact your provider to request your complete treatment history and ask them to submit the PA request through your plan's provider portal.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Provider must request approval before dispensing Highmark provider portal
Step Therapy Must try/fail TNF inhibitor first Plan formulary or PA criteria
Formulary Status Non-preferred (most plans) or preferred (Medicaid) Member portal or drug list
Quantity Limits 160mg initial, 80mg maintenance every 4 weeks PA criteria documents
TB Screening Negative test within 12 months Clinical documentation
Appeal Deadline 60-180 days from denial (varies by plan) Denial letter or member handbook

Step-by-Step: Fastest Path to Approval

1. Gather Your Documentation (Patient)

Collect your insurance card, complete list of previous treatments with dates, and any denial letters. Contact your provider's office to request copies of your medical records showing psoriasis severity or joint symptoms.

2. Provider Submits PA Request

Your dermatologist or rheumatologist submits the prior authorization through your Blue Cross plan's provider portal. For Highmark plans, this includes Form 22645 with clinical justification.

Timeline: 14 days standard response (72 hours for urgent cases)

3. Document Step Therapy Requirements

Your provider must show you've tried and failed (or can't tolerate) at least one TNF inhibitor like Humira (adalimumab) or Enbrel (etanercept). Include specific dates, doses, duration, and reason for failure.

4. Include Severity Metrics

For psoriasis: PASI score, body surface area (BSA) percentage, or photos. For psoriatic arthritis: joint counts, functional impairment measures, or imaging results showing joint damage.

5. Submit Required Labs

Negative tuberculosis test within 12 months, hepatitis screening, and complete blood count. Some plans also require liver function tests.

6. Follow Up on Decision

Most Pennsylvania Blue Cross plans respond within 14 days. If approved, the authorization typically lasts 6-12 months with renewal options up to 18 months.

7. Appeal if Denied

If denied, you have 60-180 days (varies by plan) to file an internal appeal, followed by external review through Pennsylvania's Insurance Department if needed.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
"Insufficient documentation of diagnosis" Submit PASI scores >12, BSA >5%, or joint count documentation
"No trial of required step therapy" Provide records showing TNF inhibitor trial with dates, doses, and failure reason
"Missing TB screening" Submit negative TB test results within past 12 months
"Quantity exceeds limits" Verify dosing matches FDA labeling: 160mg week 0, 80mg weeks 2-12, then q4w
"Not medically necessary" Include treatment guidelines from AAD or ACR supporting biologic use
Tip: The most common fixable denial is incomplete step therapy documentation. Make sure your provider includes specific medication names, dates tried, maximum doses reached, and exact reason for discontinuation (e.g., "developed injection site reactions" vs. "side effects").

Appeals Process for Pennsylvania Blue Cross Plans

Internal Appeals

Timeline: File within 60-180 days of denial (check your specific plan) How to submit:

  • Highmark: Mail to P.O. Box 890035, Camp Hill, PA 17089-0035
  • Independence Blue Cross: Call 1-888-678-7012 or submit via member portal
  • Include: Denial letter, medical records, provider letter explaining medical necessity

Response time: 30 days for standard appeals, 72 hours for expedited

Pennsylvania External Review (New 2024)

If your internal appeal is denied, Pennsylvania's new Independent External Review Program offers a state-supervised second opinion.

Eligibility: Final adverse benefit determination from internal appeal Timeline: 4 months to file after final denial Process: Submit request online or by mail to PA Insurance Department Decision time: 45 days standard, 72 hours expedited Success rate: Approximately 50% of external reviews overturn insurer denials

Note: Pennsylvania's external review program launched in January 2024 and has already helped hundreds of patients get coverage for initially denied treatments. The independent review organizations include physician specialists who evaluate cases based on medical evidence.

When Alternatives Make Sense

Before pursuing a lengthy appeal, consider whether formulary alternatives might work for your condition:

IL-17 Inhibitor Alternatives

  • Cosentyx (secukinumab): Often preferred on formularies, dual indication for psoriasis and psoriatic arthritis
  • Skyrizi (risankizumab): IL-23 inhibitor with potentially lower step therapy requirements

TNF Inhibitor Options

  • Humira (adalimumab): Most commonly required as first-line biologic
  • Enbrel (etanercept): Alternative TNF inhibitor if Humira contraindicated

When to Request a Formulary Exception

Consider requesting an exception to try Taltz first if:

  • You have inflammatory bowel disease (TNF inhibitors may worsen IBD)
  • Previous serious infections with TNF inhibitors
  • Heart failure (contraindication to TNF inhibitors)
  • Specific injection device needs due to dexterity issues

Counterforce Health specializes in helping patients navigate these complex prior authorization requirements by analyzing denial letters and crafting targeted, evidence-backed appeals that address each plan's specific criteria.

Switching Logistics & Coordination

Timing Between Biologics

When switching from a failed biologic to Taltz:

  • From adalimumab, infliximab, or other IL-17 inhibitors: Wait 2 weeks
  • From ustekinumab or IL-23 inhibitors: Wait 4 weeks
  • Safety monitoring: No full washout needed for inefficacy; wait for adverse event resolution

Provider Coordination

Dermatology + Rheumatology: If you have both psoriasis and psoriatic arthritis, ensure both specialists coordinate their treatment recommendations. Joint letters from both providers strengthen PA requests.

Pharmacy Benefits: Specialty pharmacies often help with PA submissions and can expedite the process. Many Blue Cross plans require specialty pharmacy dispensing for biologics.

Costs & Patient Support Options

Manufacturer Support

Taltz Savings Program: Eligible patients may pay as little as $5 per month for commercially insured patients (verify current terms).

Foundation Assistance

  • Patient Advocate Foundation
  • Good Days (formerly Chronic Disease Fund)
  • HealthWell Foundation

These programs may help with copays for patients who don't qualify for manufacturer programs.

State Programs

Pennsylvania residents may qualify for additional assistance through the state's pharmaceutical assistance programs, particularly for seniors or those with specific income levels.

FAQ

How long does Blue Cross Blue Shield PA take in Pennsylvania? Standard prior authorization requests receive responses within 14 days. Urgent requests are processed within 72 hours. Highmark and Independence Blue Cross follow similar timelines.

What if Taltz is non-formulary on my plan? You can request a formulary exception through your provider. Include documentation of why formulary alternatives are inappropriate or contraindicated for your specific case.

Can I request an expedited appeal? Yes, if your condition poses an immediate health threat or if waiting for standard processing would significantly worsen your condition. Your provider must submit the expedited request with supporting clinical documentation.

Does step therapy apply if I've failed biologics outside Pennsylvania? Yes, treatment history from other states counts toward step therapy requirements. Ensure your provider includes complete records from previous providers.

What happens if my appeal is denied? After exhausting internal appeals, you can request external review through Pennsylvania's Insurance Department within 4 months. The state-supervised review has approximately a 50% success rate.

Can my provider request a peer-to-peer review? Yes, most Blue Cross plans allow providers to request a discussion with the plan's medical director. This can sometimes resolve denials without formal appeals.

From our advocates: We've seen cases where patients initially denied for Taltz were approved after their providers submitted more detailed step therapy documentation. One common issue is providers noting "patient failed Humira" without specifying the exact reason—whether it was lack of efficacy, injection site reactions, or another specific issue. The more specific the documentation, the stronger the case for approval.

Understanding your Blue Cross Blue Shield plan's specific requirements in Pennsylvania is crucial for getting Taltz covered. The state's new external review program provides an important safety net, but thorough preparation of your initial prior authorization request remains the fastest path to approval. When working with your healthcare team, focus on documenting clear medical necessity and specific reasons why alternative treatments haven't worked for your condition.

Counterforce Health helps patients and providers navigate complex insurance requirements by turning denials into targeted appeals with the right evidence and documentation. Their platform analyzes your specific plan's criteria and helps build stronger cases for coverage approval.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by specific Blue Cross Blue Shield plan and individual circumstances. Always verify current requirements with your insurance plan and consult your healthcare provider for medical decisions. For additional help with insurance appeals in Pennsylvania, contact the Pennsylvania Insurance Department consumer services division.

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