By Counterforce Health Team in Turalio (pexidartinib) —

How to Get Turalio (Pexidartinib) Covered by Blue Cross Blue Shield of Texas: Prior Authorization Guide and Appeal Process

Answer Box: Fastest Path to Approval

Turalio (pexidartinib) is covered by Blue Cross Blue Shield of Texas for TGCT but requires prior authorization, REMS enrollment, and specialty pharmacy dispensing. The fastest path: (1) Ensure your prescriber and you complete REMS enrollment at TURALIOREMS.com, (2) Have your provider submit a PA request with TGCT diagnosis, imaging showing surgical ineligibility, and medical necessity documentation, (3) Use an in-network specialty pharmacy for dispensing. Coverage is limited to 120 capsules per 30 days on all BCBSTX formularies.

First step today: Contact your prescriber to begin REMS enrollment and gather required clinical documentation for the prior authorization request.

Table of Contents

  1. Before You Start: Plan Verification
  2. Coverage Requirements at a Glance
  3. Step-by-Step: Fastest Path to Approval
  4. What Documentation You Need
  5. Submitting Your Prior Authorization Request
  6. Timeline and Follow-Up
  7. Common Denial Reasons and Solutions
  8. Appeals Process for BCBS Texas
  9. Cost-Saving Options
  10. Frequently Asked Questions

Before You Start: Plan Verification

First, confirm you have the right type of Blue Cross Blue Shield of Texas plan. Self-funded employer plans (ERISA) follow different appeal rules than state-regulated plans. Check your insurance card or call BCBSTX member services at the number on your card to verify:

  • Your plan type (commercial, marketplace, or employer-sponsored)
  • Whether your plan is state-regulated or self-funded
  • Your current formulary tier for Turalio
  • In-network specialty pharmacy options
Note: Texas has strong patient appeal rights for state-regulated plans, including access to independent external review through the Texas Department of Insurance.

Coverage Requirements at a Glance

Requirement Details Where to Find
Prior Authorization Required for all BCBSTX plans BCBSTX Drug Lists
Formulary Status Non-preferred (NP) Same source
Quantity Limit 120 capsules per 30 days Same source
Specialty Pharmacy Required dispensing channel BCBSTX provider portal
REMS Enrollment Mandatory for prescriber and patient TURALIOREMS.com
Diagnosis Code M12.2 (Villonodular synovitis) ICD-10 coding standards
Appeal Deadline 180 days from denial Texas Insurance Code

Step-by-Step: Fastest Path to Approval

1. Complete REMS Enrollment (Patient & Prescriber)

Who does it: Both you and your prescriber
Timeline: Allow 1-2 business days
How: Visit TURALIOREMS.com or call 1-833-887-2546

2. Gather Clinical Documentation

Who does it: Your healthcare team
Timeline: 1-3 days depending on records availability
What's needed: TGCT diagnosis with imaging, surgical consultation notes, liver function tests

3. Submit Prior Authorization Request

Who does it: Your prescriber's office
How: Through BCBSTX provider portal or designated PA forms
Timeline: Same day submission once documents are ready

4. Identify In-Network Specialty Pharmacy

Who does it: You or your prescriber's office
How: Contact BCBSTX member services or check provider directory
Timeline: 1 day to confirm network status

5. Follow Up on PA Status

Who does it: You or your prescriber's office
When: After 5-7 business days
How: Call BCBSTX or check online portal

6. Coordinate Dispensing if Approved

Who does it: Specialty pharmacy
Timeline: 1-3 business days for first fill
Requirements: Valid REMS enrollment and approved PA

7. Plan for Ongoing Monitoring

Who does it: Your prescriber
What: Weekly liver function tests initially, ongoing safety monitoring per REMS requirements

What Documentation You Need

Essential Clinical Documentation

  • TGCT diagnosis confirmation with ICD-10 code M12.2
  • MRI imaging showing tumor extent and location
  • Surgical consultation notes documenting why surgery isn't feasible or appropriate
  • Baseline liver function tests (ALT, AST, bilirubin, alkaline phosphatase)
  • Previous treatment history including any prior therapies attempted

REMS Program Requirements

Both prescriber and patient must complete enrollment and certification through the Turalio REMS program due to hepatotoxicity risks. This includes:

  • Prescriber training certification
  • Patient enrollment form and registry participation
  • Commitment to required liver monitoring schedule

Insurance-Specific Forms

Access the current BCBSTX prior authorization form through:

  • Provider portal login at BCBSTX.com
  • Member services phone line
  • Your prescriber's existing PA form library
Tip: Always use the most current PA form version, as requirements can change quarterly.

Submitting Your Prior Authorization Request

Electronic Submission (Preferred)

Most efficient method is through the BCBSTX provider portal where your prescriber can:

  • Submit PA requests electronically
  • Track approval status in real-time
  • Receive automated updates on decisions
  • Upload supporting documentation directly

Alternative Submission Methods

If electronic submission isn't available:

  • Fax to the PA department (number provided on PA form)
  • Mail to the address specified on current PA forms
  • Phone submission for urgent cases (verify availability)

Clean Submission Checklist

✓ Complete PA form with all required fields
✓ TGCT diagnosis with ICD-10 code M12.2
✓ Supporting imaging (MRI reports)
✓ Surgical consultation notes
✓ REMS enrollment confirmation
✓ Baseline lab results
✓ Prescriber attestation of medical necessity

Timeline and Follow-Up

Standard Processing Times

  • Initial PA review: 15-30 days for standard requests
  • Expedited review: 72 hours if clinical urgency is documented
  • Appeals: 30 days for pre-service, 60 days for post-service claims

When to Follow Up

Call BCBSTX if you haven't received a decision within:

  • 7 business days for expedited requests
  • 20 business days for standard requests

Sample Follow-Up Script

"I'm calling to check on the status of a prior authorization request for Turalio (pexidartinib) submitted on [date]. The patient name is [name] and member ID is [ID]. Can you provide the current status and expected decision timeline?"

Document all reference numbers and representative names for your records.

Common Denial Reasons and Solutions

Denial Reason Solution
Missing TGCT diagnosis Submit pathology report or specialist consultation confirming diagnosis
Surgical options not addressed Obtain orthopedic or surgical consultation documenting why surgery isn't appropriate
REMS enrollment incomplete Complete both prescriber and patient REMS enrollment before resubmission
Insufficient imaging Provide complete MRI report showing tumor characteristics and extent
Medical necessity unclear Submit detailed clinical notes explaining functional limitations and treatment goals

Appeals Process for BCBS Texas

Internal Appeal (First Level)

Deadline: 180 days from denial notice
How to file: Call member services or submit written appeal
Decision timeline: 30 days for pre-service, 60 days for post-service
Required: Original denial letter, additional clinical documentation, prescriber letter of medical necessity

External Review (Independent Review Organization)

Eligibility: Available after internal appeal denial for state-regulated plans
Deadline: 4 months from final internal denial
Process: BCBSTX provides IRO request form with denial notice
Timeline: 20 days standard, 5 days expedited
Cost: Paid by BCBSTX
Decision: Binding on the insurance company

Texas Department of Insurance Resources

  • IRO assistance: 1-866-554-4926
  • General consumer help: 1-800-252-3439
  • Online resources: TDI Consumer Help
Important: Self-funded employer plans follow federal appeal rules, not Texas state processes. Verify your plan type before proceeding.

Cost-Saving Options

Manufacturer Support

Daiichi Sankyo may offer patient assistance programs. Contact their patient support services to inquire about:

  • Copay assistance cards
  • Patient assistance programs for uninsured/underinsured patients
  • Bridge therapy programs during appeals

Foundation Grants

Several nonprofit organizations provide grants for specialty medications:

  • Patient Advocate Foundation
  • HealthWell Foundation
  • Chronic Disease Fund

State Programs

Texas residents may qualify for additional assistance through:

  • Texas Health and Human Services programs
  • Local community health centers with sliding fee scales

Frequently Asked Questions

How long does BCBS Texas prior authorization take for Turalio? Standard review takes 15-30 days. Expedited review (with documented clinical urgency) takes up to 72 hours.

What if Turalio isn't on my formulary? Turalio is listed on BCBSTX formularies as non-preferred with prior authorization required. If you have an older plan, request a formulary exception with medical necessity documentation.

Can I get an expedited appeal if denied? Yes, if a delay would jeopardize your health. Your prescriber must provide clinical justification for the expedited timeline.

Does BCBS Texas require step therapy for Turalio? Current formulary listings don't specify step therapy requirements, but you may need to document why surgery (the standard first-line treatment) isn't appropriate.

What happens if I need Turalio while my appeal is pending? Request expedited review at each appeal level. For urgent cases, your prescriber can request a bridge supply or temporary approval.

Are there alternatives if BCBS Texas continues to deny coverage? Off-label options like imatinib or nilotinib are sometimes considered, though evidence is limited. Discuss with your oncologist or rheumatologist.

From our advocates: We've seen Turalio approvals succeed when providers include comprehensive surgical consultation notes explaining why resection isn't feasible—whether due to location, patient factors, or risk of functional impairment. The key is painting a complete clinical picture that shows Turalio as the most appropriate treatment option.

For patients and clinicians navigating complex prior authorization requirements, Counterforce Health helps turn insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with each insurer's specific requirements, potentially saving weeks in the appeals process.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and should not replace professional medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with your specific plan and consult your healthcare provider for medical decisions. For additional assistance with insurance appeals in Texas, contact the Texas Department of Insurance at 1-800-252-3439.

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