By Counterforce Health Team in Turalio (pexidartinib) —

How to Get Turalio (Pexidartinib) Covered by Blue Cross Blue Shield in Ohio: Complete PA Forms, Appeals, and Approval Guide

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

Quick Path to Approval: Blue Cross Blue Shield Ohio (Anthem) covers Turalio (pexidartinib) as a specialty drug requiring prior authorization and REMS enrollment. Success requires: (1) confirmed TGCT diagnosis with imaging/pathology, (2) documentation that surgery isn't feasible or appropriate, (3) baseline liver function tests, and (4) submission through CarelonRx portal or Availity. Start by calling the number on your ID card to confirm your exact plan type and pharmacy benefit manager, then download the current PA form from Anthem Ohio's provider portal.

Table of Contents

  1. Plan Types & Coverage Implications
  2. Formulary Status & Tier Placement
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Network Rules
  5. Submission Process & Forms
  6. Common Approval Patterns
  7. Appeals Process for Ohio Members
  8. Cost-Share Basics
  9. Verification Resources
  10. FAQ

Plan Types & Coverage Implications

Blue Cross Blue Shield coverage in Ohio is primarily administered through Anthem Blue Cross and Blue Shield, which serves most commercial, Medicare Advantage, and Medicaid (MyCare Ohio) members. Your specific plan type affects how Turalio coverage works:

  • Commercial Plans (HMO/PPO/EPO): Use Anthem's standard prior authorization process through CarelonRx or Availity portal
  • Medicare Advantage: May have additional CMS-mandated coverage protections and expedited appeal rights
  • MyCare Ohio (Medicaid): Follows Ohio Medicaid PA requirements with state-supervised external review options
  • Self-Funded Employer Plans: May use Anthem administration but follow ERISA rules for appeals
Note: Check your ID card for the exact plan name and pharmacy benefit manager (often CarelonRx for Anthem plans).

Formulary Status & Tier Placement

Turalio is classified as a specialty oncology drug on most Anthem/BCBS Ohio formularies. Based on Anthem's drug policies, it typically appears as:

  • Formulary Status: Covered but non-preferred (higher tier)
  • Prior Authorization: Required for all non-Medicare plans
  • Quantity Limits: May apply based on FDA-labeled dosing
  • REMS Requirement: Mandatory enrollment in Turalio REMS program

Alternative Agents: No other FDA-approved systemic drugs exist for TGCT. Off-label options like imatinib or nilotinib are sometimes considered but lack approval for this indication.

Prior Authorization Requirements

Core Clinical Criteria

Anthem's Turalio policy (CRX-ALL-0568-20) requires ALL of the following:

Requirement Documentation Needed
Diagnosis Tenosynovial giant cell tumor (TGCT/GCT-TS/PVNS) confirmed by pathology or imaging
Surgery Status Disease not amenable to surgical resection OR surgeon's note stating unacceptable morbidity risk
Severity Symptomatic disease with severe morbidity or functional limitations
Infection Status No active/chronic hepatitis B/C or HIV infection
Age Adult (≥18 years) unless specific pediatric exception

Exclusion Criteria (Automatic Denial)

  • Metastatic TGCT
  • Active hepatitis B, C, or HIV infection
  • Failure to meet all listed approval criteria

REMS and Safety Requirements

Turalio requires enrollment in the TURALIO REMS program due to serious liver injury risk:

  • Prescriber enrollment with completed training
  • Patient counseling and enrollment documentation
  • Baseline liver function tests (ALT, AST, bilirubin)
  • Ongoing monitoring schedule per FDA label
  • REMS-certified pharmacy (typically Biologics specialty pharmacy)

Specialty Pharmacy Network Rules

Network Requirements

Anthem Ohio plans typically require Turalio to be dispensed through:

  1. Biologics Specialty Pharmacy (exclusive REMS provider)
  2. In-network status verification required for coverage
  3. Direct prescription routing to avoid coverage delays
Tip: Call the member services number on your ID card to confirm Biologics is in-network for your specific plan before prescribing.

REMS Coordination

The TURALIO4U program coordinates:

  • Benefit verification
  • REMS enrollment for prescriber and patient
  • Prescription routing to Biologics (fax: 1-800-823-4506)
  • Financial assistance screening

Submission Process & Forms

Step-by-Step: Fastest Path to Approval

  1. Verify Coverage (Day 1)
    • Call member services number on ID card
    • Confirm plan type and pharmacy benefit manager
    • Ask about Turalio formulary status and PA requirements
  2. Complete REMS Enrollment (Days 1-3)
    • Prescriber enrolls at TURALIO REMS portal
    • Complete patient counseling and enrollment forms
    • Order baseline liver function tests
  3. Gather Documentation (Days 2-5)
    • TGCT diagnosis confirmation (pathology/imaging)
    • Surgical consultation notes
    • Functional assessment documentation
    • Lab results (hepatitis panel, HIV status, LFTs)
  4. Submit Prior Authorization (Day 5-7)
  5. Route Prescription (Same day as PA)
    • Fax prescription and REMS forms to Biologics: 1-800-823-4506
    • Ensure REMS enrollment is complete before dispensing

Required Documentation Checklist

  • ✓ Completed PA form with all clinical fields
  • ✓ Office notes documenting TGCT symptoms and functional impact
  • ✓ Imaging reports (MRI showing disease extent)
  • ✓ Surgical consultation stating non-resectability or high morbidity risk
  • ✓ Baseline liver function tests
  • ✓ Negative hepatitis B/C and HIV testing
  • ✓ REMS enrollment confirmation

Common Approval Patterns

Strongest Applications Include:

Clear Medical Necessity: Detailed documentation of how TGCT affects daily function, work capacity, or quality of life with specific examples.

Surgical Rationale: Orthopedic oncology consultation clearly stating why surgery would cause "major morbidity or functional loss" (e.g., joint destruction, neurovascular risk).

Guideline Alignment: Reference to FDA labeling and any relevant specialty society recommendations for TGCT management.

Safety Compliance: Demonstrated understanding of hepatotoxicity risk with specific monitoring plan and baseline normal LFTs.

From Our Advocates: We've seen the strongest approvals when providers include a brief cover letter summarizing how the patient meets each specific Anthem criterion, with references to attached documentation. This prevents reviewers from having to search through multiple documents for key information.

Appeals Process for Ohio Members

Internal Appeals

If your PA is denied, Ohio BCBS/Anthem members have structured appeal rights:

Appeal Level Timeline How to File Decision Timeline
Level 1 Internal 180 days from denial Availity portal or written request 15-30 days standard
Expedited Internal Same day if urgent Call member services + written follow-up 72 hours
External Review 180 days from final denial File with plan, forwarded to Ohio DOI 45 days standard, 72 hours expedited

External Review in Ohio

Ohio provides independent external review through the Ohio Department of Insurance:

  • Consumer Hotline: 1-800-686-1526
  • Process: Independent Review Organizations (IROs) with medical experts
  • Binding Decision: Insurer must comply if IRO overturns denial
  • Success Rates: National data shows ~80% of appealed PA denials are overturned in Medicare Advantage plans

Appeal Documentation Strategy

Address Specific Denial Reasons: Obtain the detailed denial letter and respond point-by-point to each cited deficiency.

Include New Evidence: Updated imaging, additional specialist opinions, or functional assessments if disease has progressed.

Cite Policy Language: Reference exact Anthem criteria and explain how patient meets each requirement.

Cost-Share Basics

Turalio costs approximately $23,850 for a 28-day supply without insurance. With Blue Cross Blue Shield Ohio coverage:

  • Specialty Tier Copay: Typically $50-$200+ per month depending on plan
  • Coinsurance: May be 20-40% of drug cost after deductible
  • Out-of-Pocket Maximum: Annual limit provides cost protection

Financial Assistance Options

  • TURALIO4U Copay Support: May reduce patient costs to $10-$25/month for eligible commercially insured patients
  • Daiichi Sankyo Patient Assistance: Free drug program for qualifying uninsured/underinsured patients
  • Foundation Grants: Organizations like Good Days, PAN Foundation may provide assistance

Verification Resources

Official Sources for Current Information

Plan-Specific Verification

Always confirm current requirements by:

  1. Calling the member services number on the insurance card
  2. Checking the most recent formulary for your specific plan
  3. Downloading current PA forms from the official portal

FAQ

Q: How long does Blue Cross Blue Shield PA take in Ohio? A: Standard PA decisions are typically made within 15-30 days. Expedited reviews for urgent cases must be completed within 72 hours.

Q: What if Turalio is non-formulary on my plan? A: Request a formulary exception with documentation that no formulary alternatives exist for TGCT. Most plans have exception processes for orphan drugs.

Q: Can I request an expedited appeal? A: Yes, if delaying Turalio would seriously jeopardize your health or ability to regain function. Document progressive joint destruction or severe functional decline.

Q: Does step therapy apply if I've tried treatments outside Ohio? A: Prior therapy documentation from any state typically counts. Include records of failed surgeries or other treatments regardless of location.

Q: What happens if my appeal is denied? A: Ohio members can request external review through the state insurance department. The decision is binding on the insurer and often more favorable than internal reviews.

Q: Do I need a specialist to prescribe Turalio? A: While not always required, having an oncologist or orthopedic oncologist prescribe improves approval odds and ensures proper safety monitoring.

When You Need Additional Support

If you're struggling with Turalio coverage despite following these steps, Counterforce Health specializes in turning insurance denials into successful appeals. Their platform analyzes denial letters, identifies specific policy requirements, and drafts evidence-backed appeals that address each payer's criteria directly. This targeted approach can significantly improve your chances of overturning a denial and getting the coverage you need.

For immediate assistance with Blue Cross Blue Shield Ohio coverage issues, contact the Ohio Department of Insurance Consumer Services Division at 1-800-686-1526. They can help navigate the appeals process and ensure your rights are protected.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies change frequently, and individual plan terms may vary. Always verify current requirements with your specific Blue Cross Blue Shield Ohio plan and consult healthcare professionals for medical decisions. Success in appeals depends on individual circumstances and proper documentation.

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