By Counterforce Health Team in Taltz (ixekizumab) —

How to Get Taltz (ixekizumab) Covered by Blue Cross Blue Shield in Washington: Complete Forms & Appeals Guide 2025

Answer Box: Getting Taltz (ixekizumab) Covered by Blue Cross Blue Shield in Washington

Blue Cross Blue Shield (BCBS) in Washington requires prior authorization for Taltz (ixekizumab), with coverage dependent on documented moderate-to-severe psoriasis, failed conventional therapies, and specialist involvement. Your fastest path to approval: (1) Verify your specific BCBS plan's formulary status via your member portal, (2) Have your dermatologist submit a complete prior authorization with PASI scores ≥10 and documented TNF inhibitor failures, and (3) Use your plan's provider portal or fax submission process. Most decisions come within 14 days for standard requests.

Start today: Call the member services number on your insurance card to confirm whether you have Premera Blue Cross, Regence BlueShield, or another BCBS entity, as each has different forms and requirements.

Table of Contents

  1. Verify Your BCBS Plan and Find the Right Forms
  2. Prior Authorization Requirements and Forms
  3. Submission Portals and Processes
  4. Specialty Pharmacy Enrollment
  5. Appeals Process for Denials
  6. Support Contacts and Resources
  7. Washington State External Review
  8. Cost Savings and Patient Assistance
  9. FAQ: Common Questions

Verify Your BCBS Plan and Find the Right Forms

Washington state has multiple BCBS entities with different policies for Taltz (ixekizumab). Your first step is identifying which specific plan you have:

Major BCBS Plans in Washington

  • Premera Blue Cross: Uses Accredo and AllianceRx Walgreens Prime as specialty pharmacies; Express Scripts handles prior authorization
  • Regence BlueShield: May use CVS Specialty or other in-network options depending on your specific plan
  • Other BCBS affiliates: Each may have unique formulary and PA requirements
Tip: Your insurance card will show the specific BCBS entity. The member services phone number is your quickest way to confirm plan details and current formulary status.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all BCBS plans Member portal or call customer service Premera PA requirements
Formulary Tier Specialty tier (high copay) Plan-specific drug list Check your member portal
Step Therapy Must try TNF inhibitor first PA form clinical criteria Premera policy 5.01.629
Specialist Required Dermatologist or rheumatologist PA submission requirements Plan-specific PA criteria
Age Restriction ≥4 years for psoriasis FDA labeling requirements Premera psoriasis policy

Prior Authorization Requirements and Forms

Key Documentation Requirements

For Moderate-to-Severe Plaque Psoriasis:

  • Confirmed diagnosis with ICD-10 codes
  • PASI score ≥10 or BSA involvement ≥3%, or involvement of sensitive areas (face, genitals, hands/feet)
  • Documentation of inadequate response to at least one conventional systemic therapy (methotrexate, cyclosporine)
  • Failed trial of at least one TNF inhibitor (Humira, Enbrel, Remicade) unless contraindicated
  • Negative TB screening and hepatitis panel
  • Prescriber must be dermatologist or in consultation with one

For Psoriatic Arthritis:

  • Active psoriatic arthritis diagnosis
  • Rheumatologist or dermatologist involvement required
  • Failed preferred agent (such as Enbrel or Rinvoq) unless clinically inappropriate

Medical Necessity Letter Checklist

Your dermatologist should include:

  • Problem statement: Severity of psoriasis with objective measures (PASI, BSA, photographs)
  • Prior treatments: Specific medications tried, dosages, duration, and reasons for discontinuation
  • Clinical rationale: Why Taltz is medically necessary vs. covered alternatives
  • Guideline citations: Reference to American Academy of Dermatology guidelines and FDA prescribing information
  • Treatment goals: Expected outcomes and monitoring plan

Submission Portals and Processes

Premera Blue Cross Submission

Provider Portal: Healthcare providers can submit PA requests through the Premera provider portal Fax: Check current fax numbers in your provider portal (numbers change periodically) Required Account: Providers need Premera portal registration

Regence BlueShield Submission

MyPrime Portal: Use the Regence provider portal for PA submissions Forms: Plan-specific prior authorization forms available through provider portal Timeline: Standard review within 14 business days

Note: Always verify current submission methods through your specific plan's provider portal, as contact information and processes are updated annually.

What to Include in Your Submission

  • Completed prior authorization form
  • Medical necessity letter from specialist
  • Chart notes documenting severity and prior treatments
  • Laboratory results (TB screening, hepatitis panel)
  • PASI scores or BSA documentation
  • Photos of affected areas (if available)

Specialty Pharmacy Enrollment

In-Network Specialty Pharmacies by Plan

Premera Blue Cross typically uses:

  • Accredo (Express Scripts specialty pharmacy)
  • AllianceRx Walgreens Prime

Other BCBS plans may include:

  • CVS Specialty
  • BioPlus Specialty Pharmacy

Enrollment Process

  1. After PA approval: Your prescriber will send the prescription to your plan's preferred specialty pharmacy
  2. Patient enrollment: The specialty pharmacy will contact you to set up delivery and administration training
  3. Insurance verification: The pharmacy confirms coverage and processes any copay assistance programs
Important: Always confirm your plan's current in-network specialty pharmacies before having prescriptions transferred, as network changes can affect coverage.

Appeals Process for Denials

Internal Appeals with BCBS

Timeline: You have 60 days from the denial date to file an internal appeal Required documents:

  • Copy of the denial letter
  • Additional medical documentation supporting medical necessity
  • Updated medical necessity letter addressing specific denial reasons

Common denial reasons and fixes:

Denial Reason How to Overturn Required Documentation
Insufficient severity documentation Submit PASI scores, BSA measurements, photos Objective severity assessments
Missing step therapy Document specific TNF inhibitor trials and failures Detailed treatment history with dates
No specialist involvement Get dermatologist consultation and letter Specialist evaluation and recommendation
Incomplete safety screening Submit TB and hepatitis testing results Current laboratory values

Expedited Appeals

For urgent medical situations where delay could seriously jeopardize your health:

  • Timeline: Decision within 72 hours
  • Requirements: Medical documentation of urgency
  • Submission: Same process as standard appeal but marked "expedited"

Washington State External Review

If your internal appeal is denied, Washington state provides robust external review rights through Independent Review Organizations (IROs).

External Review Process

Eligibility: Available after exhausting internal appeals with BCBS Timeline: You have 180 days from the final internal denial to request external review Cost: No fees for consumers Decision timeline: 45 days for standard review, 72 hours for expedited

How to Request External Review

  1. Contact method: Submit request to the Washington State Office of the Insurance Commissioner or directly to your insurer
  2. Required information: Copy of final internal denial, medical records, and explanation of why coverage should be provided
  3. IRO assignment: The state automatically assigns a certified Independent Review Organization
  4. Binding decision: If the IRO overturns the denial, BCBS must provide coverage
Consumer Advocacy: Call the OIC Consumer Advocacy line at 1-800-562-6900 for help with appeals or complaints about mishandled cases.

Support Contacts and Resources

BCBS Member Services

  • Premera Blue Cross: 800-722-1471
  • Regence BlueShield: Check member ID card for current number
  • What to ask: Formulary status, PA requirements, appeal deadlines, specialty pharmacy network

Provider Support Lines

  • Prior authorization status: Available through provider portals
  • Peer-to-peer review requests: Can be requested if initial PA is denied
  • Case management: For complex cases requiring additional coordination

Washington State Resources

Cost Savings and Patient Assistance

Manufacturer Support Programs

Taltz Savings Program: Eli Lilly offers copay assistance for eligible patients with commercial insurance

  • May reduce copays to as low as $5 per month
  • Income and insurance restrictions apply
  • Cannot be combined with government insurance (Medicare, Medicaid)

Additional Resources

  • Patient advocacy organizations: National Psoriasis Foundation provides resources and support
  • State pharmaceutical assistance programs: Check with Washington state for additional programs
  • Foundation grants: Various patient assistance foundations offer help with specialty medication costs

FAQ: Common Questions

How long does BCBS prior authorization take in Washington? Standard PA decisions typically come within 14 business days. Expedited reviews for urgent cases are completed within 72 hours.

What if Taltz is non-formulary on my plan? You can request a formulary exception by demonstrating medical necessity and failure of formulary alternatives. The process is similar to standard PA but may require additional documentation.

Can I request an expedited appeal if my condition worsens? Yes. If delay in treatment could seriously jeopardize your health, you can request expedited review with a decision within 72 hours.

Does step therapy apply if I failed TNF inhibitors outside Washington? Yes, documented treatment failures from other states count toward step therapy requirements. Ensure your new provider has complete records from previous treatments.

What happens if my appeal is denied? You can request external review through Washington's IRO process. This provides an independent medical review that is binding on your insurer if decided in your favor.

How often do I need to renew Taltz authorization? Most BCBS plans approve Taltz for 12-month periods, requiring reauthorization annually with documentation of continued medical necessity and treatment response.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters, identifies the specific denial basis, and creates evidence-backed appeals that meet payer requirements. We specialize in complex specialty medications like Taltz, ensuring your appeal includes the right clinical documentation, guideline citations, and procedural requirements to maximize approval odds.

Sources & Further Reading

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about treatment decisions and insurance coverage. Coverage policies change frequently—verify current requirements with your specific BCBS plan before making treatment decisions. For personalized help with complex coverage issues, consider working with Counterforce Health or similar patient advocacy services.

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