By Counterforce Health Team in Tavneos (avacopan) —

How to Get Tavneos (Avacopan) Covered by Blue Cross Blue Shield in New York: Complete Guide to Prior Authorization, Appeals, and Billing Codes

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

To get Tavneos (avacopan) covered by Blue Cross Blue Shield in New York, you'll need prior authorization with documented severe active ANCA-associated vasculitis (GPA or MPA), use as adjunctive therapy with standard immunosuppressants, and prescription by a specialist. Start by having your rheumatologist, nephrologist, or pulmonologist complete the plan-specific specialty drug PA form with your diagnosis (ICD-10: I77.82 or M31.7/M31.3x), ANCA status, and current treatment regimen. If denied, New York's external appeal law gives you strong rights to independent review through the Department of Financial Services.

First step today: Contact your specialist to confirm your chart documents severe active GPA/MPA and request they initiate the prior authorization process with your specific Blue Cross Blue Shield plan.

Table of Contents

Understanding Your Blue Cross Blue Shield Plan

Blue Cross Blue Shield in New York operates through several independent entities, each with its own prior authorization requirements for Tavneos:

  • Empire BlueCross BlueShield/Anthem (commercial plans)
  • Highmark Blue Cross Blue Shield of Western New York
  • Excellus BlueCross BlueShield (Central/Upstate NY)

First, check your member ID card to identify which Blue Cross Blue Shield entity covers you. This determines which specific forms and submission portals you'll need to use.

Tavneos is almost always covered under the pharmacy benefit as a specialty medication, not as a medical benefit "buy-and-bill" drug. This means it requires pharmacy prior authorization rather than medical prior authorization.

ICD-10 Coding for ANCA-Associated Vasculitis

Proper diagnosis coding is critical for Tavneos approval. Your provider should use one of these specific ICD-10 codes:

ICD-10 Code Description When to Use
I77.82 Antineutrophilic cytoplasmic antibody [ANCA] vasculitis When documented as "ANCA-associated vasculitis" without specific subtype
M31.7 Microscopic polyangiitis (MPA) When specifically diagnosed as MPA
M31.30/M31.31 Wegener's granulomatosis/GPA When specifically diagnosed as granulomatosis with polyangiitis

Essential documentation your provider needs in your chart:

  • Confirmed diagnosis of severe active GPA or MPA
  • ANCA status (c-ANCA/PR3 or p-ANCA/MPO positive/negative)
  • Organ involvement (kidney, lung, ENT, skin, nerves)
  • Disease activity measures (BVAS score if required by your plan)
  • Current treatment regimen including immunosuppressants and glucocorticoids
Tip: Ask your specialist to document "severe active ANCA-associated vasculitis" explicitly in your chart, as this matches the FDA indication for Tavneos.

Product Coding: NDC, Units, and Billing

Understanding Tavneos dosing and billing units helps prevent common rejections:

Standard Dosing:

  • Strength: 10 mg capsules only
  • FDA dose: 30 mg twice daily with food (3 capsules twice daily)
  • Daily total: 6 capsules per day
  • 30-day supply: 180 capsules
  • NDC example: 73556-0168-02 (verify current NDC with pharmacy)

Dose Reduction: When taking strong CYP3A4 inhibitors, dose reduces to 30 mg once daily (3 capsules daily = 90 capsules per 30 days).

Most Blue Cross Blue Shield plans apply a quantity limit of 180 capsules per 30 days aligned with FDA labeling. Requests above this limit require additional prior authorization documentation.

Step-by-Step: Fastest Path to Approval

1. Verify Your Plan's Requirements

Who does it: You or your clinic
What to do: Check if your specific Blue Cross Blue Shield plan requires prior authorization for Tavneos
How: Use your plan's prior authorization lookup tool or call member services
Timeline: Same day

2. Gather Required Documentation

Who does it: Your specialist (rheumatologist, nephrologist, or pulmonologist)
What to gather:

  • Confirmed GPA or MPA diagnosis with ICD-10 code
  • ANCA test results
  • Current immunosuppressive therapy details
  • Disease severity documentation
  • Previous treatment history

Timeline: 1-2 business days

3. Complete the Specialty Drug PA Form

Who does it: Your provider's office
What to use: Plan-specific specialty drug prior authorization form
Key sections to complete:

  • Patient demographics and member ID
  • Prescriber specialty and NPI
  • Diagnosis: severe active ANCA-associated vasculitis
  • Current medications: rituximab or cyclophosphamide plus glucocorticoids
  • Requested dose: 30 mg twice daily (180 capsules/30 days)

4. Submit Through Preferred Channel

Electronic submission: Use your plan's provider portal when available
Fax submission: Use plan-specific fax number on the PA form
Attachments: Include clinic notes, lab results, and ANCA testing

5. Track Your Request

Standard timeline: 3-5 business days for non-urgent requests
Urgent timeline: 24-72 hours when marked urgent
Follow up: Contact provider services if no response within expected timeframe

6. If Approved

Authorization number: Save this for pharmacy claims
Approved quantity: Confirm 180 capsules/30 days or adjusted amount
Duration: Note approval period (typically 6-12 months)

7. If Denied

Review denial letter: Understand specific reason for denial
Gather additional documentation: Address gaps identified in denial
File internal appeal: Use plan's appeal process first
Consider external appeal: If internal appeal fails, use New York's external review

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Documentation Needed
Not severe enough Submit disease activity scores and organ involvement BVAS score ≥16 or ≥11 with multi-organ involvement
Not adjunctive therapy Document concurrent immunosuppressants Current rituximab or cyclophosphamide plus steroid regimen
Wrong prescriber specialty Have specialist submit or co-sign request Rheumatology, nephrology, or pulmonology provider
Missing ANCA documentation Submit laboratory results Positive c-ANCA/PR3 or p-ANCA/MPO results
Step therapy required Document contraindications or failures Prior adverse reactions or treatment failures

Appeals Process in New York

New York provides robust appeal rights through the Department of Financial Services (DFS). Here's your roadmap:

Internal Appeals (Required First Step)

  • Deadline: Follow your plan's internal appeal timeline
  • How to file: Use plan-specific appeal form
  • Documentation: Include additional clinical evidence addressing denial reasons

External Appeals Through DFS

  • When available: After final adverse determination on medical necessity
  • Deadline: 4 months from final internal denial
  • How to file: Complete DFS external appeal application
  • Timeline: 30 days for standard appeals, 72 hours for expedited
  • Cost: Maximum $25 (waived for financial hardship)

For urgent situations: Mark appeals as expedited if delay could seriously jeopardize your health. Expedited external appeals are decided within 72 hours for urgent drug denials.

From our advocates: We've seen cases where patients initially denied for Tavneos succeeded on external appeal by emphasizing the unique mechanism of action and steroid-sparing benefits. The key was having the specialist clearly explain why standard therapy alone wasn't sufficient for this patient's severe disease manifestations.

Frequently Asked Questions

How long does Blue Cross Blue Shield prior authorization take in New York?
Standard requests typically take 3-5 business days. Urgent requests marked for expedited review are processed within 24-72 hours.

What if Tavneos isn't on my plan's formulary?
You can request a formulary exception by demonstrating medical necessity and documenting why preferred alternatives aren't appropriate for your specific case.

Can I get an expedited appeal if I'm currently hospitalized?
Yes, New York allows expedited external appeals for urgent situations. Document how delay could seriously jeopardize your health or ability to regain function.

Does step therapy apply if I tried treatments outside New York?
Your treatment history should transfer. Provide documentation of prior therapies tried and their outcomes, regardless of where treatment occurred.

What happens if my appeal is approved?
The insurer must cover the treatment and may need to refund your appeal filing fee. For external appeals, the decision is binding on your insurance plan.

How much does Tavneos cost without insurance?
Typical retail pricing is approximately $17,000 per 30-day supply. With insurance coverage, your out-of-pocket costs depend on your plan's specialty drug copay or coinsurance structure.

When to Contact New York Regulators

Contact the New York State Department of Financial Services if:

  • Your insurer doesn't respond within required timeframes
  • You believe your plan is improperly applying utilization management
  • You need help understanding your external appeal rights
  • You want to file a complaint about claims handling

DFS Contact Information:

  • Website: dfs.ny.gov
  • Consumer hotline: 1-800-342-3736
  • Online complaint portal available through DFS website

Counterforce Health specializes in turning insurance denials into successful appeals for patients needing specialty medications like Tavneos. Their platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that address each payer's specific requirements. If you're facing a complex denial or need help navigating the appeals process, their expertise in payer-specific workflows can significantly improve your chances of approval.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice. Always consult with your healthcare provider about treatment decisions and work with your insurance plan directly for coverage determinations. Coverage policies and procedures may change; verify current requirements with your specific Blue Cross Blue Shield plan and the New York Department of Financial Services.

For additional support navigating insurance appeals and prior authorizations, Counterforce Health offers specialized assistance in developing evidence-based appeals tailored to your specific payer's requirements.

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