By Counterforce Health Team in Tracleer (bosentan) —

How to Get Tracleer (bosentan) Covered by Blue Cross Blue Shield in New York: Forms, Appeals & Contact Directory

Answer Box: Getting Tracleer Covered by BCBS New York

Blue Cross Blue Shield New York requires prior authorization for Tracleer (bosentan) with mandatory REMS enrollment and specialty pharmacy dispensing. The fastest path: 1) Ensure your cardiologist/pulmonologist and you are enrolled in the Tracleer REMS program, 2) Complete baseline liver function and pregnancy tests (if applicable), 3) Submit the BCBS-specific PA form with PAH diagnosis documentation. Standard approval takes 72 hours; appeals must be filed within 180 days of denial.

Table of Contents

  1. Start Here: Verify Your Plan & Find the Right Forms
  2. Required Forms for Tracleer Prior Authorization
  3. Submission Portals & Online Access
  4. Fax Numbers & Mailing Addresses
  5. Specialty Pharmacy Requirements
  6. Member Services & Provider Support Lines
  7. New York State Appeals & Consumer Protection
  8. Update Schedule: When to Re-Check Resources
  9. FAQ: Common Questions About BCBS NY Coverage

Start Here: Verify Your Plan & Find the Right Forms

New York has multiple Blue Cross Blue Shield entities, and your specific contact information depends on which plan you have. Check your member ID card for these identifiers:

Major BCBS Plans in New York:

  • Anthem Blue Cross Blue Shield (most commercial plans)
  • Excellus BlueCross BlueShield (upstate regions)
  • Highmark Blue Cross Blue Shield of Western New York (Buffalo area, Medicaid)
  • Empire BlueCross BlueShield (downstate, some employer groups)
Tip: Your member ID card will show the specific Blue plan name and customer service number. Use this plan-specific number for fastest service rather than generic BCBS contacts.

Coverage Requirements at a Glance:

Requirement Details Where to Find It
Prior Authorization Required for all bosentan products Plan formulary
REMS Enrollment Mandatory for prescriber & patient FDA REMS Site
Specialty Pharmacy Must use in-network certified pharmacy Plan member portal
Step Therapy Generic bosentan first (unless contraindicated) Plan policy documents
Diagnosis PAH (WHO Group 1) only BCBS medical policy

Required Forms for Tracleer Prior Authorization

Core Documentation Needed

1. Prior Authorization Request Form

  • Each BCBS NY plan has its own PA form
  • Find yours at your plan's provider portal or member services
  • Anthem NY: Available through Availity portal
  • Excellus: Check provider resources

2. Clinical Documentation Requirements

  • PAH diagnosis confirmation with hemodynamic data (right heart catheterization showing mPAP ≥25 mmHg, PCWP ≤15 mmHg, PVR >3 Wood units)
  • Prescriber credentials (must be cardiologist or pulmonologist)
  • REMS enrollment verification for both prescriber and patient
  • Baseline laboratory results: ALT, AST, pregnancy test (if applicable)
  • Step therapy documentation if requesting brand Tracleer over generic bosentan

Clinician Corner: Medical Necessity Letter Checklist

When writing the medical necessity letter, include:

✓ Problem statement: "Patient has WHO Group 1 PAH confirmed by [specific diagnostic method]"
✓ Prior treatments: Document any previous PAH therapies and outcomes
✓ Clinical rationale: Why bosentan is appropriate based on FDA labeling
✓ Monitoring plan: Commitment to monthly LFTs and pregnancy testing per REMS requirements
✓ Dosing justification: Starting dose and titration plan within FDA-approved limits

Submission Portals & Online Access

Primary Online Submission Methods:

Anthem Blue Cross Blue Shield NY:

  • Provider Portal: Availity.com (preferred method)
  • Member Portal: Available through plan website for patient-initiated requests
  • Account Required: Yes, providers must register for Availity access

Excellus BlueCross BlueShield:

  • Provider Portal: Available at excellusbcbs.com
  • Specialty Pharmacy Coordination: Integrated with portal submissions
  • Upload Requirements: PDF format for clinical notes and labs

Highmark BCBS Western NY:

Note: Online portals typically process requests faster than fax/mail submissions and provide real-time status updates.

Fax Numbers & Mailing Addresses

Highmark BCBS Western NY

Prior Authorization Fax Lines:

  • Medical Prior Auth: 1-800-964-3627
  • Retail Pharmacy: 1-844-490-4877
  • Medical Injectables: 1-844-493-9206

Mailing Address: BlueCross BlueShield of Western New York
P.O. Box 62509
Virginia Beach, VA 23466-2509

Anthem Blue Cross Blue Shield NY

General Provider Services: 1-800-331-1476
Prior Authorization: Submit via Availity portal (fax numbers vary by request type)

Mailing Address: Anthem Blue Cross and Blue Shield New York
P.O. Box 105557
Atlanta, GA 30348-5557

Cover Sheet Best Practices

  • Include member ID, provider NPI, and "URGENT" if expedited review needed
  • List all attached documents (PA form, clinical notes, labs, REMS verification)
  • Include direct callback number for questions

Specialty Pharmacy Requirements

REMS-Certified Specialty Pharmacy Requirement Tracleer can only be dispensed through specialty pharmacies enrolled in the FDA REMS program. Your BCBS NY plan maintains a network of approved specialty pharmacies.

Onboarding Steps

  1. Verify Network Status: Call member services to confirm which specialty pharmacies are in-network
  2. Transfer Prescription: Your prescriber sends the prescription directly to the specialty pharmacy
  3. Patient Enrollment: Specialty pharmacy will contact you to complete REMS enrollment and provide drug education
  4. Coordinate Shipping: Most specialty pharmacies offer home delivery with temperature-controlled packaging

Common In-Network Specialty Pharmacies:

  • Specialty pharmacy networks vary by BCBS NY plan
  • Contact member services at the number on your ID card for current list
  • Ensure the pharmacy is both REMS-certified AND in your plan's network

Member Services & Provider Support Lines

Key Phone Numbers by Plan

Anthem Blue Cross Blue Shield NY:

  • General Member Services: Number on your ID card
  • Provider Services: 1-800-331-1476
  • Hours: Monday–Friday, 8 a.m.–5 p.m. ET

Highmark BCBS Western NY:

  • Provider Services & Prior Auth: 1-866-231-0847 (TTY 711)
  • General Inquiries: 1-716-887-6900
  • Address: 257 West Genesee Street, Buffalo, NY 14202

Excellus BlueCross BlueShield:

  • Customer Service: Contact page for current numbers
  • Provider Relations: Available through main customer service line

What to Ask When You Call

  • For PA Status: "I need to check the status of a prior authorization for Tracleer (bosentan) for member [ID number]"
  • For Denials: "I received a denial for Tracleer. Can you explain the specific reason and appeal process?"
  • For REMS Questions: "Can you confirm if my specialty pharmacy is REMS-certified and in-network?"

New York State Appeals & Consumer Protection

Internal Appeals with BCBS

Timeline: File within 180 days of denial notice
Method: Online portal, phone, fax, or mail
Decision Time: 72 hours for standard requests, 24 hours for urgent

External Appeals Through NY State

If your internal appeal is denied, you have powerful rights under New York law.

New York State Department of Financial Services (DFS)

Expedited External Appeals:

  • Timeline: 72 hours for standard, 24 hours for urgent drug denials
  • Cost: Maximum $25 fee (waived for financial hardship or Medicaid)
  • Binding Decision: The external reviewer's decision is final and binding on BCBS

Additional Consumer Support

Community Health Advocates (CHA)

  • Phone: 888-614-5400
  • Service: Free help with insurance appeals and denials
  • Coverage: All New York residents
From Our Advocates: "We've seen several successful external appeals for specialty PAH medications in New York. The key is submitting comprehensive clinical documentation and citing FDA labeling when BCBS denies based on 'experimental' claims. New York's external review system is particularly strong for rare disease medications."

Update Schedule: When to Re-Check Resources

Quarterly Updates (Every 3 Months):

  • Formulary changes and tier placements
  • Prior authorization requirements
  • Specialty pharmacy network updates

Annual Updates (January):

  • New plan year policies and procedures
  • Appeals deadlines and processes
  • Member services contact information

As-Needed Updates:

  • FDA REMS program changes
  • New York state insurance regulations
  • Plan mergers or acquisitions

Where to Check for Updates:

FAQ: Common Questions About BCBS NY Coverage

How long does BCBS New York prior authorization take for Tracleer? Standard requests: 72 hours. Expedited requests (when delay could harm health): 24 hours. Submit complete documentation to avoid delays.

What if Tracleer is non-formulary on my BCBS NY plan? Request a formulary exception. You'll need to demonstrate medical necessity and that covered alternatives are inappropriate. Use your plan's exception request process.

Can I request an expedited appeal if my Tracleer is denied? Yes. If delaying treatment could seriously jeopardize your health, request expedited review. Both internal (with BCBS) and external (with NY State DFS) appeals offer expedited timelines.

Does step therapy apply if I've tried other PAH medications outside New York? Previous treatment history from other states should count toward step therapy requirements. Provide documentation of prior therapies and outcomes to support your request.

What happens if my prescriber isn't REMS-enrolled? Your prescriber must enroll in the Tracleer REMS program before BCBS will approve coverage. This is an FDA requirement, not a plan restriction. The enrollment process typically takes 1-2 business days.

Can I use a non-specialty pharmacy for Tracleer? No. FDA REMS requirements mandate specialty pharmacy dispensing. Your BCBS NY plan will only cover Tracleer when dispensed through an in-network, REMS-certified specialty pharmacy.

Resources to Streamline Your Approval Process

Getting specialty medications approved can feel overwhelming, especially when you're managing a serious condition like pulmonary arterial hypertension. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed responses. Their platform identifies the specific denial basis—whether it's prior authorization criteria, step therapy requirements, or "not medically necessary" determinations—and drafts point-by-point rebuttals aligned with your plan's own rules.

For medications like Tracleer, the system pulls appropriate evidence from FDA labeling, peer-reviewed studies, and specialty guidelines, weaving them into appeals with required clinical facts like diagnosis codes, prior treatment failures, and monitoring plans. This comprehensive approach can significantly improve your chances of approval while reducing the time and stress involved in the appeals process.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage policies and procedures change frequently. Always verify current requirements with your specific BCBS New York plan and consult your healthcare provider about treatment decisions. For personalized assistance with insurance denials and appeals, consider consulting with Counterforce Health or other qualified patient advocacy services.

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