By Counterforce Health Team in Tysabri (natalizumab) —

How to Get Tysabri (Natalizumab) Covered by Blue Cross Blue Shield in Washington: Complete Prior Authorization and Appeals Guide

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

Tysabri (natalizumab) requires prior authorization from all Blue Cross Blue Shield plans in Washington. The fastest path to approval: (1) Ensure TOUCH program enrollment for both patient and prescriber, (2) Submit comprehensive prior authorization with MRI documentation and prior therapy failures, (3) Use your plan's provider portal (Availity for Premera/Regence). If denied, you have 180 days to appeal internally, then can request external review through Washington's IRO process. Start by calling your BCBS plan's provider services to confirm current submission requirements.

Table of Contents

  1. Coverage Overview: BCBS Plans in Washington
  2. Prior Authorization Requirements
  3. Step-by-Step: Fastest Path to Approval
  4. Common Denial Reasons & Solutions
  5. Appeals Process for Washington BCBS Members
  6. Clinical Documentation Checklist
  7. Cost and Financial Assistance
  8. When to Contact Washington Insurance Commissioner
  9. Frequently Asked Questions

Coverage Overview: BCBS Plans in Washington

The major Blue Cross Blue Shield carriers in Washington—Premera Blue Cross and Regence BlueShield—both cover Tysabri (natalizumab) as a specialty medication under the medical benefit. Coverage requires prior authorization and compliance with FDA's TOUCH prescribing program due to the risk of progressive multifocal leukoencephalopathy (PML).

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before treatment Provider portal or fax submission Premera PA Requirements
TOUCH Enrollment FDA-mandated risk program Both patient and prescriber must enroll Tysabri HCP Guide
Formulary Status Specialty tier (30-33% coinsurance) Plan formulary documents Premera Specialty Drug List
Site of Care Contracted infusion centers only Provider directory Plan member portal
Appeals Deadline 180 days from denial Internal appeal process Washington OIC Appeals Guide

Prior Authorization Requirements

All Washington BCBS plans require prior authorization for Tysabri, with specific documentation requirements:

Core Clinical Criteria

  • Confirmed diagnosis of relapsing forms of multiple sclerosis or moderately to severely active Crohn's disease
  • Age 18 or older and management by appropriate specialist (neurologist for MS, gastroenterologist for Crohn's)
  • Documentation of treatment failure or intolerance to at least two preferred disease-modifying therapies
  • TOUCH program enrollment for both prescriber and patient with signed consent forms

Required Documentation

  • Recent MRI results (within 3 months for baseline)
  • Complete treatment history with outcomes and reasons for discontinuation
  • Current disease activity assessment (relapse rate for MS, disease severity scores for Crohn's)
  • JCV antibody testing results
  • Specialist's letter of medical necessity
Note: Missing TOUCH enrollment documentation is the most common reason for initial denial, according to Washington Apple Health clinical criteria.

Step-by-Step: Fastest Path to Approval

1. Verify Insurance Coverage

Who: Patient or clinic staff
Action: Call the member services number on insurance card to confirm Tysabri is covered under the medical benefit
Timeline: Same day

2. Complete TOUCH Program Enrollment

Who: Both prescriber and patient
Action: Register at TouchProgram.com and complete all required forms
Timeline: 1-2 business days

3. Gather Clinical Documentation

Who: Clinical team
Action: Collect MRI reports, treatment history, lab results, and specialist notes
Timeline: 2-3 days

4. Submit Prior Authorization

Who: Prescriber or authorized staff
Action: Submit via Availity portal for Premera or plan-specific portal for other BCBS carriers
Timeline: Same day submission

5. Follow Up on Decision

Who: Clinic staff
Action: Check portal or call plan within 5-7 business days for status update
Timeline: BCBS must respond within 15 business days for standard requests

6. Appeal if Denied

Who: Patient with prescriber support
Action: Submit internal appeal with additional documentation within 180 days
Timeline: 30 days for plan response

7. Request External Review if Needed

Who: Patient
Action: Contact Washington OIC for Independent Review Organization (IRO) review
Timeline: Must request within 4 months of final internal denial

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Missing TOUCH enrollment Submit proof of enrollment TOUCH confirmation letters
Inadequate prior therapy documentation Provide detailed treatment history Medical records showing failures/intolerances
Missing MRI documentation Submit recent brain MRI Radiology reports within 3 months
Overlapping DMT therapy Clarify treatment timeline Medication reconciliation
Quantity limits exceeded Justify dosing frequency Clinical notes supporting q4w dosing

Success Tip: When appealing, directly address each denial reason listed in your EOB and provide specific documentation to counter each point.

Appeals Process for Washington BCBS Members

Washington state provides robust consumer protections for insurance appeals, including access to independent external review.

Internal Appeals Timeline

First-Level Appeal:

  • Deadline: 180 days from denial notice
  • Plan Response: 30 calendar days (72 hours for urgent)
  • How to Submit: Written appeal via mail, fax, or online portal

Second-Level Appeal (if available):

  • Deadline: 30 days from first-level denial
  • Plan Response: 30 calendar days
  • Requirements: May include peer-to-peer review opportunity

External Review (IRO Process)

If internal appeals are unsuccessful, Washington members can request external review by an Independent Review Organization:

  • Deadline: 4 months from final internal denial
  • IRO Response: 45 days (72 hours for expedited)
  • Cost: Free to member (insurer pays IRO fees)
  • Decision: Binding on the insurance plan

Contact Information:

  • Washington Office of Insurance Commissioner: 1-800-562-6900
  • Online: insurance.wa.gov
From Our Advocates: We've seen several Washington BCBS members successfully overturn Tysabri denials at the IRO level by submitting comprehensive neurologist letters that directly cited FDA prescribing information and addressed PML risk assessment. The key was demonstrating that the denial criteria didn't align with current MS treatment guidelines.

Clinical Documentation Checklist

For Multiple Sclerosis Patients

Required Clinical Documentation:

  • Confirmed relapsing MS diagnosis with McDonald criteria
  • Baseline brain MRI (within 3 months)
  • JCV antibody test results
  • Documentation of ≥2 prior DMT failures or intolerances
  • Current relapse rate and disability progression
  • Neurologist's letter of medical necessity
  • TOUCH program enrollment confirmation

Helpful Additional Documentation:

  • EDSS scores showing disability progression
  • Recent gadolinium-enhancing lesions on MRI
  • Quality of life impact assessments
  • Previous hospitalization records for relapses

Medical Necessity Letter Template

Your neurologist's letter should address:

  1. Patient identification and confirmed MS diagnosis
  2. Disease activity including relapse frequency and MRI findings
  3. Prior therapy failures with specific medications, durations, and reasons for discontinuation
  4. Clinical rationale for Tysabri based on disease severity
  5. PML risk assessment including JCV antibody status
  6. Monitoring plan including regular MRI surveillance

Cost and Financial Assistance

Insurance Coverage

  • Specialty tier coinsurance: Typically 30-33% after deductible
  • Annual out-of-pocket maximum: Varies by plan (verify with member services)
  • Site of care: Must use contracted infusion centers

Patient Assistance Programs

  • Biogen Support Program: May offer copay assistance for eligible patients
  • Foundation grants: Multiple Sclerosis Association of America and National MS Society offer financial assistance
  • State programs: Washington Apple Health (Medicaid) covers Tysabri with prior authorization

Counterforce Health helps patients and clinicians navigate the complex prior authorization process for specialty medications like Tysabri. Our platform analyzes denial letters and creates targeted, evidence-backed appeals that align with each payer's specific requirements, significantly improving approval rates for patients who need access to critical treatments.

When to Contact Washington Insurance Commissioner

Contact the Washington Office of Insurance Commissioner if:

  • Your BCBS plan doesn't respond within required timelines
  • You believe the denial violates Washington insurance law
  • The appeals process isn't being followed correctly
  • You need help understanding your rights

Contact Information:

  • Phone: 1-800-562-6900
  • Website: insurance.wa.gov
  • Consumer Advocacy team can assist with appeals and complaints

Frequently Asked Questions

How long does BCBS prior authorization take in Washington? Standard prior authorization decisions are due within 15 business days. Urgent requests must be processed within 72 hours.

What if Tysabri is non-formulary on my plan? You can request a formulary exception by demonstrating medical necessity and failure of preferred alternatives. The appeals process is the same.

Can I request an expedited appeal? Yes, if delay in treatment could seriously jeopardize your health. Expedited appeals must be decided within 72 hours.

Does step therapy apply if I failed therapies outside Washington? Yes, documented treatment failures from other states count toward meeting step therapy requirements.

What happens if the IRO overturns my denial? The BCBS plan must authorize coverage and process payment. IRO decisions are legally binding on the insurer.

Can I get help with my appeal? Yes, the Washington OIC Consumer Advocacy team provides free assistance with appeals. Counterforce Health also offers specialized support for complex medication appeals.

How much will Tysabri cost with BCBS coverage? Costs vary by plan, but specialty medications typically have 30-33% coinsurance after meeting your deductible. Contact member services for your specific costs.

What if my employer plan is self-funded? Self-funded ERISA plans may not be subject to Washington state appeal rights, but many voluntarily follow similar processes. Contact the U.S. Department of Labor if needed.

Sources & Further Reading

Disclaimer: This information is for educational purposes and should not be considered medical or legal advice. Insurance coverage and requirements may vary by specific plan and change over time. Always verify current requirements with your insurance carrier and consult with your healthcare provider about treatment decisions. For personalized assistance with insurance appeals, contact the Washington Office of Insurance Commissioner at 1-800-562-6900.

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