By Counterforce Health Team in Turalio (pexidartinib) —

How to Get Turalio (Pexidartinib) Covered by Blue Cross Blue Shield in Michigan: Complete PA Timeline & Appeal Guide

Answer Box: Getting Turalio Covered by Blue Cross Blue Shield in Michigan

Blue Cross Blue Shield of Michigan requires prior authorization for Turalio (pexidartinib) to treat TGCT, with approval contingent on REMS enrollment, confirmed diagnosis, and surgical non-feasibility documentation. The fastest path: (1) Enroll all parties in REMS at turaliorems.com (1-3 days), (2) Submit PA via Prime Therapeutics portal with complete documentation, (3) Expect decision in 5-7 business days (24-72 hours if expedited). If denied, appeal within 180 days internally, then file Michigan DIFS external review within 127 days for binding decision.

Table of Contents

  1. What Affects Turalio Approval Timing
  2. Pre-Submission Preparation (0-2 Days)
  3. Submission to Initial Review (1-5 Days)
  4. Additional Information Requests (1-7 Days)
  5. Decision Window & Outcomes
  6. If Denied: Appeal Timeline
  7. Renewal Cycles & Maintenance
  8. Timeline Visual & Milestones
  9. Time-Saving Tips
  10. Common Denial Reasons & Solutions
  11. Michigan Appeals Playbook
  12. FAQ

What Affects Turalio Approval Timing

Several factors influence how quickly Blue Cross Blue Shield of Michigan processes your Turalio prior authorization:

REMS Enrollment Status: The FDA-mandated TURALIO REMS program requires enrollment of prescribers, patients, and pharmacies before any PA submission. This typically takes 1-3 business days but is the most common cause of delays.

Documentation Completeness: BCBS Michigan requires specific evidence including TGCT diagnosis via MRI/pathology, surgical consultation notes, baseline liver function tests, and hepatitis screening. Missing any component triggers information requests that add 5-7 days.

Submission Method: Electronic submissions via the Prime Therapeutics portal (BCBS Michigan's pharmacy partner) process faster than fax submissions. The University of Michigan-specific Turalio PA form streamlines the process for applicable members.

Urgency Classification: Standard reviews take 5-7 business days, while expedited reviews (requiring physician certification of serious health jeopardy) complete within 24-72 hours per Michigan regulations.

Pre-Submission Preparation (0-2 Days)

Essential Checklist

REMS Enrollment (Start Immediately):

  • Prescriber enrollment at turaliorems.com with training completion
  • Patient enrollment with baseline lab requirements
  • Pharmacy certification verification (call 1-855-887-2546 for status)

Clinical Documentation:

  • MRI report showing TGCT with hemosiderin deposits
  • Pathology confirmation (ICD-10: M12.2 for villonodular synovitis)
  • Surgical consultation explicitly stating infeasibility or unacceptable morbidity risk
  • Baseline labs: AST, ALT, total bilirubin, alkaline phosphatase ≤ upper limit normal
  • Hepatitis B (HBsAg, HBcAb) and Hepatitis C antibody results

Insurance Verification:

  • Confirm active BCBS Michigan coverage
  • Verify Turalio is on formulary (listed on 2026 Clinical Drug List)
  • Check prior authorization requirements via member portal
Tip: Start REMS enrollment immediately while gathering other documentation. Incomplete REMS enrollment causes automatic PA denials regardless of medical necessity.

Submission to Initial Review (1-5 Days)

Michigan State Requirements

Per Michigan FIS 2288 regulations, BCBS Michigan must respond to prior authorization requests within:

  • 15 calendar days for standard requests
  • 72 hours for expedited requests (when delay would seriously jeopardize health)

What Reviewers Check First

  1. REMS Compliance: Enrollment confirmations for all parties
  2. Diagnosis Verification: ICD-10 coding and imaging consistency
  3. Surgical Contraindication: Clear documentation of non-surgical status
  4. Safety Requirements: Normal baseline liver function tests

Submission Methods

Electronic (Fastest): Prime Therapeutics provider portal with real-time tracking Fax: Standard PA forms to number on member ID card Phone: Member services for urgent submissions (verify current number)

Additional Information Requests (1-7 Days)

If BCBS requests additional information, you have 72 hours to respond to maintain expedited status, or up to 21 days for standard requests per Michigan regulations.

Common Requests:

  • Updated liver function tests if baseline values are borderline
  • More detailed surgical consultation notes
  • Functional assessment scores (pain, mobility impact)
  • Prior treatment history documentation

Response Strategy: Submit requested information immediately via the same method as original submission. Include reference number and patient identifier on all documents.

Decision Window & Outcomes

Typical Approval Timeline

Submission Type Initial Review Decision Total Timeline
Standard (Complete) 1-2 days 5-7 business days 6-9 days
Standard (Info Needed) 1-2 days 10-14 business days 11-16 days
Expedited Same day 24-72 hours 1-3 days

Reading Your Approval Letter

Approved PAs typically include:

  • Quantity limits (usually 30-day initial supply)
  • Renewal requirements (every 6-12 months)
  • Designated specialty pharmacy requirements
  • Monitoring requirements reference

If Denied: Appeal Timeline

Internal Appeal Process

Deadline: 180 days from denial notice for commercial plans Timeline: 30 days for standard appeals, 72 hours for expedited Submission: Same portal/method as original PA with additional supporting evidence

Michigan External Review

If internal appeal fails, Michigan's Department of Insurance and Financial Services (DIFS) offers binding external review:

Deadline: 127 days from final internal denial Timeline: Standard varies by complexity; expedited within 72 hours Success Rate: Approximately 47% of external reviews overturn denials Filing: Online form or FIS 0018 paper form

Contact DIFS: 877-999-6442 (8am-5pm ET weekdays)

Renewal Cycles & Maintenance

Turalio approvals typically require renewal every 6-12 months. Start renewal process 30-60 days before expiration to prevent treatment gaps.

Renewal Requirements:

  • Updated liver function tests
  • Treatment response assessment
  • Continued REMS compliance
  • No disease progression documentation
  • Ongoing surgical non-feasibility

Timeline Visual & Milestones

Day 0: Start REMS enrollment
Day 1-3: Complete enrollment, gather docs
Day 4: Submit PA
Day 5-7: BCBS review period
Day 8: Decision (if standard timeline)
Day 30+: Internal appeal (if denied)
Day 157+: DIFS external review (if needed)

Time-Saving Tips

  1. Use Electronic Portals: Prime Therapeutics portal offers fastest processing and real-time status updates
  2. Bundle All Evidence: Submit complete documentation package initially to avoid information requests
  3. Leverage Specialty Pharmacy: BCBS-designated specialty pharmacies can expedite processing
  4. Maintain REMS Status: Keep all parties enrolled to prevent renewal delays
  5. Document Everything: Save all submission confirmations and reference numbers

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Incomplete REMS Complete enrollment for all parties Enrollment confirmations with dates
Missing surgical evaluation Obtain explicit surgical consultation Notes stating surgical non-feasibility
Abnormal liver tests Repeat labs when normalized Normal AST, ALT, bilirubin, alk phos
Insufficient diagnosis Provide comprehensive imaging MRI with hemosiderin deposits noted
Step therapy Document contraindications to alternatives Medical necessity for Turalio specifically

Michigan Appeals Playbook

Level 1: Internal Appeal

Who: BCBS Michigan utilization review Deadline: 180 days from denial Timeline: 30 days standard, 72 hours expedited How: Same submission method as original PA

Level 2: External Review

Who: Michigan DIFS Independent Review Organization Deadline: 127 days from final internal denial Timeline: 72 hours expedited, variable standard How: DIFS online form

Required Documents for Appeals

  • Original denial letter
  • All medical records supporting medical necessity
  • Physician letter detailing urgency (for expedited)
  • Evidence of failed alternatives or contraindications

FAQ

Q: How long does BCBS Michigan PA take for Turalio? A: Standard requests: 5-7 business days. Expedited requests: 24-72 hours. Timeline depends on REMS enrollment completion and documentation quality.

Q: What if Turalio is non-formulary on my plan? A: Turalio appears on BCBS Michigan's 2026 formulary but requires PA. Non-formulary drugs may be covered via medical exception process.

Q: Can I request an expedited appeal in Michigan? A: Yes, both BCBS internal appeals and DIFS external reviews offer expedited processing (72 hours) when physician certifies serious health jeopardy.

Q: Does step therapy apply to Turalio? A: BCBS may require documentation of surgical evaluation, but traditional step therapy is less common for orphan oncology drugs like Turalio.

Q: What happens if my REMS enrollment expires? A: Automatic coverage termination. Renewal requires re-enrollment of all parties before PA renewal submission.

Q: Who can help with the appeals process in Michigan? A: Michigan DIFS consumer assistance (877-999-6442), patient advocacy organizations, and Counterforce Health specializes in turning denials into successful appeals.

From our advocates: "We've seen Turalio approvals succeed when families front-load the REMS enrollment and surgical consultation documentation. The key is demonstrating that surgery truly isn't an option, not just that it's difficult or risky. BCBS reviewers look for explicit statements from orthopedic or surgical oncology specialists about unacceptable morbidity or functional loss."

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to create point-by-point rebuttals aligned with payer requirements, pulling the right clinical evidence and regulatory citations to support medical necessity arguments.

For complex cases like Turalio, where REMS requirements and surgical contraindications must be precisely documented, Counterforce Health streamlines the appeal process by identifying specific denial reasons and crafting responses that meet both FDA safety requirements and payer coverage criteria.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and individual circumstances. Always verify current requirements with your specific BCBS Michigan plan and consult healthcare providers for medical decisions. For insurance questions, contact Michigan DIFS at 877-999-6442.

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