By Counterforce Health Team in Tysabri (natalizumab) —

How to Get Tysabri (Natalizumab) Covered by Blue Cross Blue Shield in Texas: Complete Guide with Forms and Appeal Templates

Answer Box: Getting Tysabri Covered by Blue Cross Blue Shield in Texas

Tysabri (natalizumab) requires prior authorization from Blue Cross Blue Shield of Texas. To get approved:

  1. Enroll in TOUCH REMS - Both patient and prescriber must complete federal enrollment before starting
  2. Submit complete PA request - Include JCV antibody results, baseline MRI, and documentation of failed DMTs via Availity portal
  3. Prepare for potential denial - Texas allows internal appeals within 180 days and external review through Independent Review Organizations

First step today: Call the number on your BCBS member ID card to verify current PA requirements and obtain necessary forms.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization PA required for all Tysabri prescriptions BCBS provider portal BCBS TX PA Codes List
TOUCH Enrollment Federal REMS program enrollment mandatory Biogen TOUCH portal FDA REMS requirement
JCV Antibody Testing Baseline and every 6 months Lab results documentation Clinical monitoring standard
MRI Documentation Baseline brain MRI required Radiology reports Clinical monitoring standard
Failed DMT Documentation Prior therapy trials/failures Medical records Formulary criteria
Response Timeline 72 hours standard, 24 hours expedited PA determination BCBS Drug Coverage

Step-by-Step: Fastest Path to Approval

1. Verify Current Coverage Status

Who: Patient
Action: Call BCBS member services (number on ID card)
Ask for: Current formulary status, PA requirements, copay amount
Timeline: 10-15 minutes

2. Complete TOUCH REMS Enrollment

Who: Both patient and prescriber
Action: Register at Tysabri TOUCH portal
Required: Complete safety training modules
Timeline: 1-2 business days for approval

3. Gather Clinical Documentation

Who: Patient with clinic support
Required documents:

  • JCV antibody test results (within 6 months)
  • Brain MRI report (baseline)
  • Complete medication history with dates
  • Documentation of DMT failures/intolerances Timeline: 1-2 weeks if tests needed

4. Submit Prior Authorization Request

Who: Prescriber or clinic staff
Method: Availity portal or Blue Approver
Include: All clinical documentation and medical necessity letter
Timeline: Same-day submission once documents ready

5. Monitor PA Status

Who: Patient and clinic
Action: Track via provider portal or member services
Follow-up: Contact after 48 hours if no response
Timeline: 72 hours for determination

6. Prepare for Potential Peer-to-Peer

Who: Prescribing physician
When: If initial PA denied
Preparation: Concise case summary, guideline references ready
Timeline: Usually scheduled within 3-5 business days

7. File Appeal if Necessary

Who: Patient or authorized representative
Method: Internal appeal first, then external review if needed
Timeline: 180 days to file internal appeal in Texas

Working with Your Doctor: Visit Preparation

Before Your Appointment

Symptom Timeline Documentation Create a detailed record of your MS symptoms and relapses:

  • Dates of relapses or symptom worsening
  • Functional impact (walking, vision, cognition)
  • Recovery time and residual effects
  • Current disability level and EDSS score if known

Treatment History Summary Document all previous MS medications:

  • Drug names and generic names
  • Start and stop dates
  • Reason for discontinuation (lack of efficacy, side effects, contraindications)
  • Specific side effects experienced
  • Duration of trials (insurance often requires adequate trial periods)

Current Functional Status Prepare to discuss:

  • Daily activities affected by MS
  • Work or school limitations
  • Quality of life impact
  • Caregiver needs

Questions to Ask Your Doctor

  1. "What specific clinical criteria does BCBS require for Tysabri approval?"
  2. "Do I meet the requirements for failed DMT trials?"
  3. "What's my JCV antibody status and PML risk stratification?"
  4. "Can you help me understand the TOUCH program requirements?"
  5. "What happens if the PA is denied initially?"

Building Your Evidence Kit

Essential Clinical Documentation

Laboratory Results

  • JCV antibody testing (ELISA index value)
  • Complete blood count with differential
  • Liver function tests
  • Vitamin D levels (if relevant to MS management)

Imaging Studies

  • Most recent brain MRI with gadolinium
  • Cervical and thoracic spine MRI if available
  • Comparison to prior scans showing disease activity

Medication History Documentation Create a comprehensive table:

Medication Dates Used Reason for Discontinuation Supporting Documentation
Interferon beta-1a MM/YYYY - MM/YYYY Breakthrough relapses Clinic notes, MRI reports
Glatiramer acetate MM/YYYY - MM/YYYY Injection site reactions Dermatology consultation
Dimethyl fumarate MM/YYYY - MM/YYYY GI intolerance Symptom diary, clinic notes

Supporting Guidelines and References

FDA Labeling Information Tysabri is FDA-approved for relapsing forms of multiple sclerosis as monotherapy. Reference the official prescribing information for approved indications and safety monitoring requirements.

Professional Society Guidelines

  • American Academy of Neurology MS treatment guidelines
  • National Multiple Sclerosis Society treatment recommendations
  • European Committee for Treatment and Research in MS (ECTRIMS) guidelines

Medical Necessity Letter Structure

Template Framework

Header Section

[Date]
Blue Cross Blue Shield of Texas
Prior Authorization Department
[Address from member ID card or provider portal]

Re: Prior Authorization Request - Tysabri (natalizumab)
Member: [Patient Name]
DOB: [Date of Birth]
Member ID: [Insurance ID Number]
Provider: [Prescribing Physician Name and NPI]

Clinical Rationale Paragraphs

  1. Diagnosis and Disease Activity
    • Confirmed MS diagnosis with McDonald criteria
    • Current relapse rate and MRI activity
    • EDSS score and functional status
  2. Prior Treatment History
    • Specific DMTs tried with dates
    • Reasons for discontinuation
    • Documentation of inadequate response or intolerance
  3. Medical Necessity for Tysabri
    • FDA-approved indication
    • Clinical evidence supporting use
    • Expected benefits and treatment goals
  4. Safety Monitoring Plan
    • TOUCH program enrollment confirmation
    • JCV antibody status and monitoring schedule
    • MRI surveillance plan
  5. Risk-Benefit Analysis
    • PML risk stratification
    • Benefits of treatment vs. risks of untreated MS
    • Patient understanding and consent

Supporting Documentation Checklist

  • Complete medical records from past 12 months
  • MRI reports with radiologist interpretation
  • JCV antibody test results
  • TOUCH enrollment confirmation
  • Prior medication trial documentation
  • Functional assessment scores
  • Patient consent for treatment

Common Denial Reasons & Solutions

Denial Reason How to Address Required Documentation
Missing TOUCH enrollment Complete enrollment before resubmission TOUCH confirmation number
Inadequate DMT trials Document specific failures/intolerances Clinic notes, medication history
Missing JCV testing Obtain current antibody status Lab results within 6 months
Insufficient MRI documentation Submit complete radiology reports Brain MRI with gadolinium
Not meeting step therapy Request exception with clinical justification Medical necessity letter
Quantity/frequency limits Justify standard dosing schedule FDA prescribing information
From Our Advocates: We've seen cases where initial denials were overturned simply by resubmitting with complete TOUCH enrollment documentation. Many providers forget this federal requirement, but it's non-negotiable for approval. Always verify enrollment status before any PA submission.

Texas Appeals Process

Internal Appeal Process

Timeline: Must file within 180 days of denial
Method: Written request to BCBS appeals department
Required: Denial letter, additional clinical evidence, physician support
Decision timeframe: 30 days for pre-service, 60 days post-service

External Review Through IRO

Eligibility: Available after internal appeal denial
Timeline: Request within 4 months of final internal denial
Process: Texas Department of Insurance assigns Independent Review Organization
Decision timeframe: 20 days standard, 5 days for urgent cases
Cost: Covered by insurance plan

IRO Request Form: LHL009 form required
Urgent Cases: Concurrent expedited internal and external review available

Contact Information for Appeals

  • Texas Department of Insurance: 1-800-252-3439
  • Office of Public Insurance Counsel: 1-877-611-6742
  • IRO Information Line: 1-866-554-4926

Cost Savings and Support Programs

Manufacturer Support Programs

Tysabri Copay Assistance Program

  • Eligible insured patients may pay as little as $0 per infusion
  • Income and insurance requirements apply
  • Apply through prescriber or infusion center

Biogen Patient Assistance Program

  • For uninsured or underinsured patients
  • Income-based eligibility criteria
  • Provides medication at no cost if qualified

Patient Advocacy Organizations

National Multiple Sclerosis Society - South Central Chapter

  • Financial navigation services
  • Insurance appeals assistance
  • Local support groups and resources
  • Contact: Texas chapter information

Multiple Sclerosis Association of America

  • Equipment and cooling vest programs
  • Educational resources and support
  • Financial assistance information

State-Specific Resources

Texas Department of Insurance Consumer Help

  • Insurance complaint filing
  • Appeals process guidance
  • Consumer protection services
  • Phone: 1-800-252-3439

When to Escalate

File a Complaint with Texas DOI

When to escalate:

  • Internal appeals process not followed properly
  • Unreasonable delays in PA decisions
  • Suspected bad faith denial practices
  • Violations of Texas insurance regulations

How to file:

  • Online complaint form at TDI website
  • Phone: 1-800-252-3439
  • Include all documentation and correspondence
  • Request investigation of insurer practices

Disability Rights Texas

  • Assists with insurance appeals
  • Advocacy for disability-related coverage
  • Legal representation in complex cases
  • Particularly helpful for Medicaid fair hearings

Private Healthcare Attorneys

  • Consider for high-value cases
  • ERISA expertise for employer plans
  • Bad faith insurance practice claims

Getting Professional Help

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to create point-by-point rebuttals aligned with each insurer's specific requirements, pulling the right clinical evidence and regulatory citations to build compelling cases for specialty medications like Tysabri.

For complex cases involving multiple denials or unusual circumstances, working with specialists who understand both the clinical requirements and insurance processes can significantly improve approval odds while reducing the administrative burden on patients and providers.

FAQ

How long does BCBS prior authorization take for Tysabri in Texas? Standard PA decisions are made within 72 hours, with expedited reviews available in 24 hours for urgent cases. Complex cases requiring peer-to-peer review may take additional time.

What if Tysabri is not on my BCBS formulary? You can request a formulary exception by submitting clinical documentation showing medical necessity. Include evidence of failed preferred alternatives and contraindications to formulary options.

Can I get an expedited appeal if my MS is worsening? Yes, Texas allows expedited internal appeals and concurrent external review for urgent medical situations. Document disease progression and risk of delay in your request.

Does step therapy apply if I failed DMTs outside of Texas? Prior treatment history from other states should be accepted with proper documentation. Ensure medical records clearly show adequate trial periods and reasons for discontinuation.

What happens if both internal and external appeals are denied? For ERISA plans, federal court review may be available. For state-regulated plans, consider filing a complaint with Texas DOI or consulting with a healthcare attorney.

How much does Tysabri cost with BCBS coverage? Costs vary by plan design, but copays for specialty infusions typically range from $50-500 per treatment. Manufacturer copay assistance can significantly reduce out-of-pocket expenses.

Do I need to use a specific infusion center? BCBS may have preferred provider networks for infusion services. Check your plan's provider directory or call member services to confirm covered facilities.

What if my doctor isn't enrolled in TOUCH? Only TOUCH-certified prescribers can prescribe Tysabri. Your doctor must complete enrollment before any PA submission. This is a federal requirement, not specific to BCBS.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan directly for specific coverage determinations. For complex appeals or legal questions, consider consulting with qualified professionals experienced in healthcare coverage issues.

If you need help navigating insurance appeals or understanding your coverage options, Counterforce Health provides specialized assistance in turning insurance denials into successful approvals through evidence-based appeal strategies.

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