By Counterforce Health Team in Tysabri (natalizumab) —

How to Get Tysabri (natalizumab) Covered by Blue Cross Blue Shield of Illinois: Complete PA Guide with Forms and Appeal Process

Answer Box: Getting Tysabri Covered by BCBS Illinois

Tysabri (natalizumab) requires prior authorization from Blue Cross Blue Shield of Illinois, plus mandatory enrollment in the FDA's TOUCH program. The fastest path: 1) Enroll in TOUCH at touchprogram.com, 2) Have your neurologist submit PA through the BCBS Illinois provider portal with complete clinical documentation, and 3) If denied, file an internal appeal within 180 days. Illinois residents have strong external review rights through the state Department of Insurance if internal appeals fail.

Table of Contents

Plan Types & Coverage Implications

Blue Cross Blue Shield of Illinois (BCBSIL) offers different plan types that affect how you access Tysabri:

HMO Plans:

PPO Plans:

  • No referral needed for specialists or specialty drugs
  • Both in-network and out-of-network providers covered (higher costs out-of-network)
  • More flexibility in choosing specialty pharmacies
  • Broader provider network access

EPO Plans:

Note: Regardless of plan type, Tysabri requires prior authorization and TOUCH program enrollment.

Formulary Status & Tier Placement

Tysabri is classified as a specialty medication on BCBSIL formularies, typically placed in Tier 5 (Preferred Specialty) or Tier 6 (Non-Preferred Specialty). The exact tier depends on your specific plan.

Coverage at a Glance

Requirement What it Means Where to Find It Source
Prior Authorization PA required before coverage BCBSIL Drug Lists Official formulary
TOUCH Enrollment FDA-mandated safety program touchprogram.com FDA requirement
Specialty Tier Tier 5-6 placement Plan-specific drug list Member portal
Step Therapy May require trying other DMTs first PA criteria documentation BCBSIL PA policies

Alternative DMTs that may be required first include:

  • Interferon beta products (Rebif, Avonex, Betaseron)
  • Glatiramer acetate (Copaxone)
  • Oral DMTs (Tecfidera, Aubagio, Gilenya)

Prior Authorization Requirements

Clinical Documentation Checklist

Your neurologist must provide:

  1. Diagnosis confirmation with ICD-10 code G35 (Multiple Sclerosis)
  2. Disease activity evidence:
    • Recent MRI showing new or enhancing lesions
    • Clinical relapses documented in medical records
    • EDSS scores if available
  3. Prior therapy documentation:
    • Previous DMTs tried and duration
    • Reasons for discontinuation (lack of efficacy, intolerance, contraindications)
    • Specific adverse events or treatment failures
  4. JCV antibody status (required within 6 months)
  5. Medical necessity letter explaining why Tysabri is appropriate
Clinician Corner: Medical Necessity Letter Elements

Include: Patient's MS phenotype and activity, prior DMT failures with specific timelines, contraindications to other therapies, clinical rationale for Tysabri selection, monitoring plan for PML risk, and references to FDA labeling or MS treatment guidelines.

TOUCH Program Enrollment

The FDA-mandated TOUCH (Tysabri Outreach: Unified Commitment to Health) program is non-negotiable for Tysabri coverage.

Required Enrollments:

  1. Patient enrollment at touchprogram.com
  2. Prescriber certification (neurologist must be TOUCH-enrolled)
  3. Infusion site registration (hospital or clinic administering Tysabri)

Process Timeline:

  • Initial enrollment: 24-48 hours for approval
  • Patient education modules: Complete before first infusion
  • Ongoing requirements: Monthly status updates, regular MRI monitoring
Tip: Start TOUCH enrollment immediately when Tysabri is being considered, as incomplete enrollment is the #1 reason for BCBSIL denials.

Specialty Pharmacy Network

BCBSIL works with Prime Therapeutics for specialty pharmacy benefit management. Tysabri coordination typically involves:

  • Buy-and-bill model for infusion centers
  • Specialty pharmacy dispensing for home delivery (rare for Tysabri)
  • Prior verification of benefits before each infusion

Contact BCBSIL Specialty Pharmacy Services to confirm preferred partners for your area (number on your insurance card).

Cost-Share Dynamics

2025 Specialty Drug Changes:

Educational Note: This information is for planning purposes only. Actual costs depend on your specific plan, deductible status, and annual out-of-pocket maximum. Always verify with member services before treatment.

Submission Process

Step-by-Step: Fastest Path to Approval

  1. Verify coverage - Call BCBSIL member services (number on insurance card)
  2. Complete TOUCH enrollment - Patient, provider, and infusion site at touchprogram.com
  3. Gather documentation - MRI reports, prior therapy records, JCV antibody results
  4. Submit PA request - Provider submits through BCBSIL provider portal
  5. Track status - Follow up within 48 hours if no response
  6. Schedule infusion - Once approved, coordinate with TOUCH-enrolled facility
  7. Monitor for determination - BCBSIL typically responds within 72 hours

Required Forms and Portals

  • Electronic submission preferred via BCBSIL provider portal
  • Fax submission available (verify current fax numbers with BCBSIL)
  • All documentation must be HIPAA compliant and include complete patient demographics

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documents
Missing TOUCH enrollment Complete enrollment for all parties TOUCH confirmation numbers
Inadequate prior therapy documentation Submit detailed treatment history Pharmacy records, clinic notes
Insufficient disease activity Provide recent MRI evidence Radiology reports, EDSS scores
Missing JCV antibody test Submit current lab results Lab report within 6 months
Step therapy not met Document contraindications/failures Medical records, adverse event documentation

Counterforce Health specializes in turning these denials into successful appeals by identifying the specific denial basis and crafting targeted, evidence-backed rebuttals that align with BCBSIL's own policy requirements.

Appeals Process for Illinois

Illinois provides robust appeal rights under the Health Carrier External Review Act.

Internal Appeal Timeline:

  • File within: 180 days of denial
  • BCBSIL decision: Within 30 days of appeal submission
  • Expedited appeals: Available for urgent medical situations

External Review Process:

  • File within: 4 months (120 days) of final internal denial
  • Illinois Department of Insurance assigns independent review organization
  • Decision timeline: Within 5 business days of receiving all information, maximum 45 days total
  • Expedited external review: 72 hours for urgent cases

Filing External Review:

Contact the Illinois Department of Insurance at 877-527-9431 or use their online portal.

Illinois-Specific Advantage: External review decisions are binding on BCBSIL, and the state pays all review costs. Success rates exceed 50% when proper medical evidence is submitted.

Cost Assistance Programs

Manufacturer Support:

  • Biogen's patient assistance program
  • Copay assistance for eligible commercial insurance patients
  • Information available at Tysabri HCP portal

Illinois Resources:

  • Illinois Attorney General Health Care Bureau: 1-877-305-5145
  • Patient advocacy organizations for complex cases
  • Legal aid societies for appeal assistance

When dealing with complex insurance denials, Counterforce Health helps patients and clinicians navigate the appeals process by analyzing denial letters, plan policies, and clinical notes to create comprehensive rebuttals that speak directly to payer requirements.

FAQ

How long does BCBS Illinois PA take for Tysabri? Typically 72 hours for standard requests, 24 hours for expedited reviews when medical urgency is documented.

What if Tysabri is non-formulary on my plan? File a formulary exception request with comprehensive medical necessity documentation and evidence that preferred alternatives are inappropriate.

Can I request an expedited appeal in Illinois? Yes, both internal and external expedited appeals are available when delays would seriously jeopardize your health.

Does step therapy apply if I failed DMTs outside Illinois? Yes, but you must provide complete documentation of prior therapies and outcomes from all treating physicians.

What happens if my TOUCH enrollment lapses? Coverage immediately stops. Re-enrollment is required before any future infusions can be covered.

How do I find TOUCH-enrolled infusion centers near me? Use the facility locator at touchprogram.com or contact BCBSIL specialty pharmacy services.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage decisions depend on individual plan terms and clinical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For complex appeals and prior authorization assistance, consider consulting with specialists like Counterforce Health who can help navigate the specific requirements of your insurance plan.

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