By Counterforce Health Team in Taltz (ixekizumab) —

How to Get Taltz (Ixekizumab) Covered by Blue Cross Blue Shield in Virginia: Complete Coding, Prior Authorization, and Appeals Guide

Quick Answer: Blue Cross Blue Shield Virginia (Anthem BCBS) requires prior authorization for Taltz (ixekizumab), with step therapy mandating failure of TNF inhibitors. Submit PA via Availity Provider Portal with proper ICD-10 codes (L40.0 for plaque psoriasis), HCPCS J3590, and documented prior therapy failures. If denied, you have 180 days for internal appeals, then 120 days for Virginia's free external review through the State Corporation Commission Bureau of Insurance.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit Paths
  2. ICD-10 Mapping for Taltz Coverage
  3. Product Coding: HCPCS, J-Codes, and NDC Numbers
  4. Clean Prior Authorization Request
  5. Frequent Coding and Billing Pitfalls
  6. Verification with Blue Cross Blue Shield Resources
  7. Quick Audit Checklist
  8. Appeals Process in Virginia
  9. Cost-Saving Programs
  10. FAQ

Coding Basics: Medical vs. Pharmacy Benefit Paths

Taltz (ixekizumab) coverage through Blue Cross Blue Shield Virginia typically falls under the medical benefit for provider-administered doses or the specialty pharmacy benefit for patient self-injection. Understanding this distinction is crucial for proper coding and authorization.

Medical Benefit Path:

  • Used when administered in physician offices or infusion centers
  • Requires HCPCS J-codes for billing
  • Subject to medical necessity review and prior authorization
  • Often involves buy-and-bill arrangements

Specialty Pharmacy Benefit Path:

  • For patient self-administration at home
  • Uses NDC codes through specialty pharmacy networks
  • Still requires prior authorization but processed differently
  • May have different copay structures
Note: Most Taltz prescriptions in Virginia go through the specialty pharmacy pathway since it's primarily a self-injected medication.

ICD-10 Mapping for Taltz Coverage

Proper diagnosis coding is essential for Taltz approval. Blue Cross Blue Shield Virginia recognizes these FDA-approved indications with specific ICD-10 codes:

Condition Primary ICD-10 Code Additional Codes Documentation Requirements
Plaque Psoriasis L40.0 (Psoriasis vulgaris) L40.70 (Moderate-severe) PASI score >10 or BSA >3%
Psoriatic Arthritis L40.50 (Unspecified PsA) L40.51-L40.59 (Specific joints) Joint involvement, imaging
Ankylosing Spondylitis M45.0-M45.9 - HLA-B27, sacroiliitis on MRI
Pediatric Psoriasis L40.0 + Z87.891 - Age ≥6 years, severity measures

Critical Documentation Words that support coding:

  • "Moderate-to-severe" (triggers L40.70)
  • "Plaque-type" (supports L40.0)
  • "Failed topical therapy" (step therapy documentation)
  • "PASI score" with numerical value
  • "Body surface area involvement"

Source: AAPC ICD-10 Coding Guidelines

Product Coding: HCPCS, J-Codes, and NDC Numbers

HCPCS and J-Code Information

Primary HCPCS Code: J3590 (Unclassified biologics)

Critical Billing Units: Taltz 80 mg = 80 billing units (not 1 unit). Always bill total milligrams as units to avoid significant underbilling.

Dosing Examples:

  • Loading dose: 160 mg (two 80 mg injections) = 160 units
  • Maintenance: 80 mg every 4 weeks = 80 units per claim

NDC Codes for 80 mg Autoinjectors

  • 0002-1445-01 (Single autoinjector)
  • 0002-1445-27 (Two-pack for loading dose)

Units Math and Modifiers

When billing Blue Cross Blue Shield Virginia:

  • Each 80 mg syringe = 80 units on the claim line
  • Loading dose (160 mg) = 160 units total
  • Use modifier -JW for drug amount discarded (if applicable)
  • No split billing across multiple dates for single administration

Clean Prior Authorization Request

A successful Taltz PA submission to Blue Cross Blue Shield Virginia should include these elements:

Required Documentation Checklist

Patient Information:

  • Full name, DOB, member ID
  • Primary and secondary insurance details
  • Contact information

Clinical Documentation:

  • ICD-10 diagnosis code (L40.0, L40.50, etc.)
  • Current disease severity measures (PASI score, BSA percentage)
  • Photos documenting skin involvement (if applicable)
  • Joint examination findings (for psoriatic arthritis)

Prior Therapy Documentation:

  • Topical treatments tried with dates and outcomes
  • Systemic therapies (methotrexate, cyclosporine) with failure reasons
  • TNF inhibitor failure (Humira, Enbrel, etc.) - this is typically required
  • Specific reasons for inadequate response or intolerance

Safety Requirements:

  • Negative TB screening within 12 months (chest X-ray, QuantiFERON)
  • Baseline laboratory values (CBC, liver function tests)
  • Hepatitis B/C screening results

Sample PA Request Structure

Patient: [Name], DOB [Date], Member ID [Number]
Diagnosis: Moderate-to-severe plaque psoriasis (ICD-10: L40.0)
Severity: PASI score 15.2, BSA 12%

Prior Therapies and Outcomes:
1. Topical corticosteroids (clobetasol) - 3 months, inadequate response
2. Methotrexate 15mg weekly - 4 months, discontinued due to nausea
3. Humira 40mg every other week - 6 months, <25% improvement in PASI

Requested: Taltz (ixekizumab) 80mg every 4 weeks after loading dose
Rationale: Patient meets criteria for biologic therapy per plan guidelines
TB screening: Negative QuantiFERON 10/15/2024

Submit via Availity Provider Portal

Frequent Coding and Billing Pitfalls

Common Unit Conversion Errors

Wrong: Billing 1 unit for 80 mg syringe Correct: Billing 80 units for 80 mg syringe

This error can result in 98% underbilling and potential audit flags.

Mismatched Diagnosis and Drug Codes

Wrong: Using L40.9 (unspecified psoriasis) with Taltz Correct: Using L40.0 (plaque psoriasis) with documented severity

Missing Prior Authorization

Never submit claims without confirmed PA approval. Blue Cross Blue Shield Virginia will deny 100% of specialty biologic claims without proper authorization.

Quantity Limit Violations

  • Standard maintenance: 2 syringes per 28 days maximum
  • Loading dose: Up to 4 syringes for initial month may be approved
  • Always verify specific quantity limits in PA approval

Site of Care Issues

Ensure billing location matches PA approval:

  • Provider office (Place of Service 11)
  • Outpatient hospital (Place of Service 22)
  • Patient home (Place of Service 12) - rare for Taltz

Verification with Blue Cross Blue Shield Resources

Before submitting any Taltz-related claims or PA requests:

Check Current Formulary Status

  1. Log into Anthem Provider Portal
  2. Search "ixekizumab" or "Taltz" in drug lookup tool
  3. Verify tier placement and PA requirements
  4. Check for any plan-specific restrictions

Confirm PA Criteria

  • Review latest medical policies for biologics
  • Check step therapy requirements (typically TNF inhibitor failure required)
  • Verify quantity limits and dosing restrictions
  • Note any age or diagnosis-specific criteria

Validate Coding

  • Cross-reference ICD-10 codes with plan's coverage policies
  • Confirm HCPCS codes are recognized for your plan type
  • Check for any state-specific billing requirements
Tip: Virginia Blue Cross Blue Shield plans may have different criteria than other states. Always verify with your specific plan's resources.

Quick Audit Checklist

Before submitting any Taltz request to Blue Cross Blue Shield Virginia:

✓ Patient Eligibility

  • Active Blue Cross Blue Shield Virginia coverage verified
  • Specialty pharmacy benefits confirmed
  • Prior authorization obtained and current

✓ Diagnosis Coding

  • Appropriate ICD-10 code selected (L40.0, L40.50, etc.)
  • Severity documentation supports coding choice
  • Comorbid conditions coded if applicable

✓ Product Coding

  • HCPCS J3590 or appropriate NDC used
  • Units calculated correctly (mg = units)
  • Quantity within approved limits

✓ Documentation

  • Prior therapy failures documented with dates
  • TNF inhibitor failure specifically noted
  • Safety screening results included
  • Prescriber specialty appropriate (dermatology/rheumatology)

✓ Submission

  • Submitted via correct portal (Availity for providers)
  • All required forms completed
  • Response timeline noted (typically 72 hours)

Appeals Process in Virginia

If Blue Cross Blue Shield Virginia denies your Taltz request, Virginia provides a robust appeals process through the State Corporation Commission Bureau of Insurance.

Internal Appeals (First Step)

Timeline: 180 days from denial notice Process:

  1. Submit written appeal to Blue Cross Blue Shield Virginia
  2. Include additional clinical documentation
  3. Request peer-to-peer review if available
  4. Decision typically within 15-30 business days

External Review (Second Step)

Virginia offers free external review through the SCC Bureau of Insurance:

Eligibility: 120 days after final internal denial Required Form: Form 216-A External Review Request Timeline:

  • Standard review: 45 days
  • Expedited review: 72 hours (if health at risk)

Contact Information:

What to Include:

  • Completed Form 216-A
  • Copy of denial notice
  • Medical records supporting medical necessity
  • Provider letter explaining why Taltz is appropriate
  • Any additional clinical evidence
From our advocates: "We've seen Virginia external reviews succeed when patients include comprehensive prior therapy documentation and specific clinical rationale. The independent medical reviewers appreciate detailed timelines showing why previous treatments failed and how Taltz addresses the patient's specific clinical situation."

The external review decision is binding on Blue Cross Blue Shield Virginia - if approved, they must provide coverage within 24-72 hours.

Cost-Saving Programs

While working through the authorization process, several programs can help reduce Taltz costs:

Manufacturer Support

Taltz Savings Card:

  • May reduce copays for commercially insured patients
  • Eligibility restrictions apply (no government insurance)
  • Visit Taltz.com or call 1-844-825-8966

Lilly Cares Foundation:

  • Patient assistance for uninsured/underinsured
  • Income-based eligibility requirements
  • Provides medication at no cost if qualified

Virginia-Specific Resources

Virginia Medicaid: If eligible, may provide coverage after PA approval Free/Charitable Clinics: Some Virginia clinics have access to manufacturer samples 340B Program: Eligible hospitals/clinics may offer reduced-cost biologics

Counterforce Health helps patients navigate these complex authorization processes by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to identify the specific reasons for denial, then drafts point-by-point rebuttals aligned with your plan's own rules, pulling the right clinical evidence and citations to support your case.

FAQ

How long does Blue Cross Blue Shield Virginia prior authorization take for Taltz? Standard PA decisions are typically made within 72 hours of complete submission. Expedited reviews (when health is at risk) may be processed within 24 hours.

What if Taltz is non-formulary on my Blue Cross Blue Shield Virginia plan? You can request a formulary exception by demonstrating medical necessity and failure of preferred alternatives. This requires additional documentation but follows the same PA process.

Does step therapy apply if I failed TNF inhibitors outside Virginia? Yes, prior therapy failures from other states count toward step therapy requirements. Ensure you have documentation from previous providers showing specific medications tried, duration, and reasons for failure.

Can I request an expedited appeal in Virginia? Yes, if your physician certifies that waiting for standard review could seriously jeopardize your health. Expedited external reviews are decided within 72 hours.

What counts as "failure" of prior therapy for Taltz approval? Blue Cross Blue Shield Virginia typically accepts: inadequate response (<75% improvement in PASI score), intolerance to side effects, or contraindications. Document specific outcomes and timeframes.

How much will Taltz cost with Blue Cross Blue Shield Virginia coverage? Costs vary by plan tier. Taltz is typically on specialty tier with higher copays ($100-500+ per month). Check your specific plan benefits or contact member services.

Can my dermatologist handle the entire PA process? Yes, dermatologists and rheumatologists can submit PA requests directly through the Availity portal. They have access to all necessary forms and can track approval status.

What happens if I move from Virginia while on Taltz? Contact your new state's Blue Cross Blue Shield plan immediately. You may need new prior authorization, but existing medical records should transfer to support continued coverage.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with your specific Blue Cross Blue Shield Virginia plan and consult with your healthcare provider for medical decisions. For personalized assistance with insurance appeals and prior authorization challenges, Counterforce Health provides specialized support in turning denials into successful approvals through evidence-based appeal strategies.

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