By Counterforce Health Team in Tysabri (natalizumab) —

How to Get Tysabri (natalizumab) Covered by Blue Cross Blue Shield in Ohio: Complete Appeals Guide with Forms and Templates

Answer Box: Fastest Path to Tysabri Coverage in Ohio

To get Tysabri (natalizumab) covered by Blue Cross Blue Shield in Ohio: First, enroll in the mandatory TOUCH REMS program at touchprogram.com or call 1-800-456-2255. Your neurologist must then submit a prior authorization through Anthem's provider portal with recent JCV antibody testing, brain MRI results, and documentation of prior DMT failure or intolerance. Standard review takes 15 business days. If denied, file an internal appeal within 60 days, then request Ohio external review within 180 days through the Ohio Department of Insurance (1-800-686-1526).

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible": Document Checklist
  4. If "Possibly Eligible": Tests to Request
  5. If "Not Yet": Alternative Options
  6. If Denied: Appeal Path Chooser
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & Fixes
  9. Appeals Playbook for BCBS Ohio
  10. Costs & Patient Assistance
  11. FAQ

How to Use This Decision Tree

This guide helps patients and clinicians navigate Tysabri coverage through Blue Cross Blue Shield plans in Ohio (primarily Anthem Blue Cross Blue Shield). Start with the eligibility triage below to determine your approval likelihood, then follow the corresponding action steps.

Ohio residents have strong appeal protections through the Ohio Department of Insurance external review process, which provides binding decisions from independent medical experts when insurers deny specialty drugs based on medical necessity.

Eligibility Triage: Do You Qualify?

Likely Eligible ✓

  • Confirmed relapsing multiple sclerosis (ICD-10: G35) or Crohn's disease
  • Failed or cannot tolerate at least one first-line DMT (interferons, glatiramer acetate, or oral agents)
  • Recent brain MRI showing active lesions or disease progression
  • Current JCV antibody status documented
  • Prescribing neurologist enrolled in TOUCH program

Possibly Eligible ⚠️

  • MS diagnosis confirmed but limited prior therapy documentation
  • Older MRI results (>6 months) or unclear activity
  • Missing JCV testing
  • Previous Tysabri use with treatment gap

Not Yet ❌

  • Newly diagnosed MS without trial of first-line therapy
  • Stable disease on current DMT
  • Active serious infections or immunocompromised state
  • Pregnancy (contraindicated)

If "Likely Eligible": Document Checklist

Your neurologist should gather these documents before submitting the prior authorization:

Required Clinical Documentation

  • TOUCH enrollment confirmation for both prescriber and patient
  • Recent brain MRI (within 6 months) with gadolinium showing lesions or activity
  • JCV antibody test results (within 6 months)
  • Prior DMT history with dates, reasons for discontinuation
  • MS diagnosis confirmation with ICD-10 code G35
  • Neurologist consultation notes supporting medical necessity

Submission Process

  1. Enroll in TOUCH: Complete at touchprogram.com or call 1-800-456-2255
  2. Submit PA: Neurologist submits through Anthem provider portal or fax to 1-877-378-4727
  3. Track status: Standard review takes 15 business days; expedited available for urgent cases
From our advocates: We've seen the strongest approvals when neurologists include a detailed timeline of prior therapies with specific dates and reasons for discontinuation. Insurance reviewers want to see clear evidence that standard treatments haven't worked before approving Tysabri.

If "Possibly Eligible": Tests to Request

Missing Documentation to Obtain

  • Current JCV antibody test: Essential for PML risk assessment
  • Updated brain MRI: Must show current disease activity or progression
  • Prior therapy records: Contact previous neurologists for treatment history
  • Specialist consultation: Ensure prescriber is enrolled in TOUCH program

Timeline for Re-Application

Allow 2-4 weeks to gather missing documentation, then resubmit. Counterforce Health can help organize clinical evidence and draft targeted appeals if initial submissions are incomplete.

If "Not Yet": Alternative Options

First-Line Therapies to Try

  • Injectable DMTs: Interferon beta-1a/1b, glatiramer acetate
  • Oral DMTs: Dimethyl fumarate, teriflunomide, fingolimod
  • Infusion alternatives: Ocrevus (ocrelizumab), Kesimpta (ofatumumab)

Exception Request Strategy

If clinical factors prevent standard step therapy:

  • Document contraindications to first-line agents
  • Provide allergy/intolerance history
  • Submit formulary exception request with supporting literature

If Denied: Appeal Path Chooser

Level 1: Internal Appeal (60-day deadline)

  • Who: Patient or prescriber can file
  • Timeline: 15 business days for decision (72 hours if expedited)
  • How: Submit via Anthem member portal or fax denial letter with additional evidence
  • Include: New clinical data, peer-reviewed studies, specialist letter

Level 2: Peer-to-Peer Review

  • When: Request during internal appeal process
  • Process: Prescriber speaks directly with Anthem medical director
  • Preparation: Have clinical notes, guidelines, and patient history ready

Level 3: External Review (180-day deadline)

  • Eligibility: After exhausting internal appeals for medical necessity denials
  • Process: File through Ohio Department of Insurance
  • Cost: Free to patients
  • Timeline: 30 days standard, 72 hours expedited
  • Outcome: Binding on insurer if overturned

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
TOUCH enrollment Federal REMS program touchprogram.com FDA requirement
Prior authorization Pre-approval needed Anthem provider portal Anthem PA process
Step therapy Try other DMTs first Plan formulary Verify with plan (833-727-2170)
JCV testing PML risk assessment Prescriber lab orders TOUCH requirements
Brain MRI Disease activity proof Radiology report Medical necessity
Specialty pharmacy Designated network Anthem RX networks Plan design

Common Denial Reasons & Fixes

Denial Reason How to Overturn
Missing TOUCH enrollment Complete enrollment at touchprogram.com; resubmit with confirmation numbers
Inadequate prior therapy Provide detailed medication history with dates and discontinuation reasons
Outdated JCV testing Obtain current JCV antibody results (within 6 months)
Insufficient MRI evidence Submit recent brain MRI with gadolinium showing active lesions
Medical necessity Include neurologist letter citing FDA labeling and MS treatment guidelines
Non-formulary status File formulary exception with clinical justification

Appeals Playbook for BCBS Ohio

Internal Appeal Process

  1. File within 60 days of denial notice
  2. Submit to: Anthem member services or provider portal
  3. Include: Original denial letter, new medical evidence, prescriber statement
  4. Timeline: 15 business days standard, 72 hours expedited
  5. Expedited criteria: Delay would seriously jeopardize health

External Review Through Ohio DOI

  1. Exhaust internal appeals first (required)
  2. File within 180 days of final adverse determination
  3. Submit: External Review Request Form
  4. Contact: 1-800-686-1526 or [email protected]
  5. Decision: Binding on insurer; 30 days standard, 72 hours expedited
Note: Self-funded employer plans follow federal ERISA rules, not Ohio external review. Check your insurance card or HR department to determine plan type.

Costs & Patient Assistance

Manufacturer Support

  • TOUCH Patient Support: Financial assistance for eligible patients
  • Biogen Patient Access: Copay assistance and appeals support
  • Contact: 1-800-456-2255 or through TOUCH program

Specialty Pharmacy Network

Ohio Anthem plans typically use:

  • Accredo Specialty Pharmacy (primary network)
  • CVS Specialty
  • BioPlus Specialty Pharmacy

Verify your specific network at Anthem's pharmacy finder or call member services.

Frequently Asked Questions

Q: How long does BCBS prior authorization take in Ohio? A: Standard review is 15 business days. Expedited review (72 hours) is available when delays would seriously jeopardize your health.

Q: What if Tysabri is non-formulary on my plan? A: File a formulary exception request with clinical justification for why Tysabri is medically necessary compared to formulary alternatives.

Q: Can I request an expedited appeal? A: Yes, if your physician certifies that a delay would seriously jeopardize your health, life, or ability to regain maximum function.

Q: Does step therapy apply if I failed medications in another state? A: Yes, prior therapy documentation from any state counts. Provide complete medication history with dates and outcomes.

Q: What happens if external review overturns the denial? A: The decision is binding on your insurer. They must provide coverage and cannot appeal the IRO decision.

Q: How much does external review cost? A: External review through Ohio DOI is free to patients. The state and insurer cover all costs.

Q: Can I continue current treatment during appeals? A: If you're already on Tysabri, ask about continuity of care provisions. For new starts, appeals don't typically provide interim coverage.

Q: What if my employer plan is self-funded? A: Self-funded ERISA plans aren't subject to Ohio external review, but many voluntarily use similar processes. Check with your HR department.

Counterforce Health specializes in turning insurance denials into successful appeals for specialty medications like Tysabri. Our platform analyzes denial letters, identifies the specific coverage gaps, and drafts evidence-based rebuttals aligned to each insurer's policies. We help patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeal processes to get life-changing treatments approved. Learn more at counterforcehealth.org.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with your specific plan and consult healthcare providers for medical decisions. For official Ohio insurance regulations and appeal procedures, contact the Ohio Department of Insurance at 1-800-686-1526.

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