By Counterforce Health Team in Vigabatrin (generic; Sabril originator Lundbeck) —

How to Get Vigabatrin (Sabril) Covered by Blue Cross Blue Shield of Texas: Complete PA Forms, Appeals, and Coding Guide

Answer Box: Getting Vigabatrin Covered in Texas

Blue Cross Blue Shield of Texas requires prior authorization for vigabatrin (Sabril) with REMS enrollment and vision testing documentation. File PA using CVS Caremark Form 548-A, include ICD-10 codes (G40.822 for infantile spasms, G40.824 for refractory seizures), and submit baseline vision results. If denied, appeal within 180 days and escalate to Texas Department of Insurance external review within 4 months. First step today: Contact your prescriber to initiate REMS enrollment and gather documentation of failed seizure medications.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping for Vigabatrin Coverage
  3. Product Coding: NDC Numbers and Billing
  4. Clean PA Request Template
  5. Common Coding Pitfalls
  6. Verification with Blue Cross Blue Shield Texas
  7. Pre-Submission Audit Checklist
  8. Appeals Process in Texas
  9. FAQ

Coding Basics: Medical vs. Pharmacy Benefit

Vigabatrin (generic) and Sabril (brand) are oral specialty medications billed through pharmacy benefits using NDC numbers—not medical benefit J-codes. This distinction matters because:

  • Pharmacy benefit: Prior authorization through CVS Caremark (for most Blue Cross Blue Shield Texas plans), specialty pharmacy dispensing required, REMS enrollment mandatory
  • Medical benefit: Would use HCPCS codes (vigabatrin has none; oral medications don't get J-codes)
  • Billing units: Calculated by days' supply and package size, not per-milligram units
Note: Some policies reference J3490 (unclassified drugs) as a fallback, but this doesn't apply to oral vigabatrin dispensed through specialty pharmacies.

ICD-10 Mapping for Vigabatrin Coverage

Accurate ICD-10 coding is essential for PA approval. Blue Cross Blue Shield Texas follows FDA-approved indications with age restrictions:

Condition Primary ICD-10 Age Requirement Documentation Keywords
Infantile Spasms G40.822 (not intractable, without status) 1 month–2 years "West syndrome," "Salaam attacks," "epileptic spasms"
Refractory Complex Partial Seizures G40.824 (intractable, without status) ≥2 years "focal impaired awareness," "failed ≥2 AEDs," "treatment-resistant"

Supporting Documentation Words

Your medical records should explicitly state:

  • For infantile spasms: Age at onset, EEG findings (hypsarrhythmia if present), developmental regression
  • For refractory epilepsy: Specific antiepileptic drugs tried, dosages reached, duration of trials, reasons for discontinuation (ineffective vs. intolerable side effects)

Research shows ICD-10 codes have 90% sensitivity for identifying treatment-resistant epilepsy when clinical documentation clearly establishes failure of at least 2 medications.

Product Coding: NDC Numbers and Billing

NDC Numbers for Vigabatrin

Sabril (brand):

  • 500 mg tablets: NDC 67386-0822-04
  • Powder packets: NDC 67386-0823-02

Generic vigabatrin: NDC varies by manufacturer; verify with your REMS-certified specialty pharmacy (common suppliers include Teva, Amneal).

No J-Code Billing

Unlike injectable seizure medications, vigabatrin lacks a specific HCPCS J-code because it's oral. Billing occurs through:

  • NDC-based pharmacy claims with quantity limits
  • Days' supply calculations (not unit-based like injectables)
  • Tier 5 specialty positioning on most Blue Cross formularies
Tip: If your pharmacy mentions J3490 (unclassified drugs), clarify that vigabatrin should bill via NDC through specialty pharmacy channels, not medical benefit.

Clean PA Request Template

Required Form: CVS Caremark 548-A

For Blue Cross Blue Shield Texas plans managed by CVS Caremark, use Form 548-A v1. Fax to 1-855-633-7673.

Essential elements:

  1. Patient demographics with correct Blue Cross member ID
  2. ICD-10 diagnosis codes (G40.822 or G40.824)
  3. Clinical criteria checklist:
    • Infantile spasms: Confirmed diagnosis + age 1 month–2 years
    • Complex partial seizures: Confirmed diagnosis + failure of ≥2 antiepileptics + age ≥2 years
  4. Prescriber attestation with signature and date

REMS Documentation Package

Attach these documents to your PA:

  • REMS enrollment confirmation for prescriber, patient, and pharmacy
  • Baseline vision testing results (age-appropriate method documented)
  • Prior medication trials with specific drugs, doses, durations, and outcomes

Counterforce Health helps automate this documentation process by identifying the specific evidence requirements for your plan and generating targeted appeal letters when initial PAs are denied.

Common Coding Pitfalls

Problem: Using G40.822 (infantile spasms code) for patients over 2 years Fix: Transition to G40.824 (intractable epilepsy) when age exceeds FDA indication

2. Missing Intractability Documentation

Problem: Coding as "intractable" without documenting ≥2 failed AEDs Fix: Include specific medication names, therapeutic doses achieved, trial durations, and failure reasons

3. Incorrect NDC Submission

Problem: Using brand Sabril NDC when prescribing generic Fix: Verify NDC with dispensing specialty pharmacy; let them handle generic substitution

4. Vision Testing Gaps

Problem: Missing baseline vision documentation or using inappropriate testing method for age Fix: Document age-appropriate method (confrontation fields <36 months, formal perimetry ≥36 months)

Verification with Blue Cross Blue Shield Texas

Before Submitting PA

  1. Confirm formulary status: Check current drug list (verify with source linked)
  2. Verify PA requirements: Call CVS Caremark at 1-866-785-5714 with member ID
  3. Check specialty pharmacy network: Ensure your pharmacy is REMS-certified and in-network

Cross-Reference Resources

  • Blue Cross Texas provider portal: Confirm current PA forms and submission methods
  • CVS Caremark: Verify member eligibility and prior authorization status
  • REMS program: Confirm enrollment status at FDA REMS database

Pre-Submission Audit Checklist

Before faxing your PA request:

  • Correct Blue Cross Texas member ID and demographics
  • Age-appropriate ICD-10 code (G40.822 for 1mo-2yr; G40.824 for ≥2yr intractable)
  • REMS enrollment documented for all parties
  • Baseline vision testing results attached
  • Prior AED trials documented with specific failures (for refractory cases)
  • Prescriber signature and date on form
  • Fax number confirmed (1-855-633-7673 for CVS Caremark 548-A)
  • Copy retained for appeals if needed

Appeals Process in Texas

Internal Appeal Timeline

If your vigabatrin PA is denied, you have 180 days to file an internal appeal with Blue Cross Blue Shield Texas:

Standard appeals: 30-day decision timeline Expedited appeals: 72 hours (request if delay would jeopardize health/vision)

Filing Methods

  • Online: Blue Cross Texas member portal (verify current link)
  • Phone: 1-888-657-6061 for member services
  • Mail: Include Health Plan Appeal Request Form with denial letter and supporting documentation
  • Pharmacy appeals: Submit to Prime Therapeutics at [email protected] or fax 1-855-212-8110

External Review (IRO)

After exhausting internal appeals, request external review within 4 months through Texas Department of Insurance:

  • Online: TDI IRO portal for fastest processing
  • Phone: 1-800-252-3439 for assistance
  • Timeline: 20 days for standard review, 5 days for urgent cases
  • Binding decision: If IRO overturns denial, Blue Cross must comply
From our advocates: We've seen families succeed with vigabatrin appeals by emphasizing the medication's unique mechanism (irreversible GABA-transaminase inhibition) and FDA's recognition that vision risks are acceptable for severe, refractory seizures when other treatments have failed. Including peer-reviewed studies showing seizure freedom rates can strengthen medical necessity arguments.

FAQ

How long does Blue Cross Blue Shield Texas PA take? Standard prior authorization: 72 hours. Expedited (urgent): 24 hours. If timelines are missed, the request is automatically approved.

What if vigabatrin is non-formulary on my plan? Request formulary exception using the same CVS Caremark form. Include documentation that preferred alternatives are contraindicated or ineffective.

Can I request an expedited appeal? Yes, if delay would jeopardize your health or vision. Document urgency with clinical notes showing seizure frequency or progression.

Does step therapy apply if I've failed seizure medications outside Texas? Yes, prior failures from any state count toward step therapy requirements. Include complete medication history with dates and outcomes.

What happens if REMS enrollment is incomplete? PA will be denied. Complete enrollment for prescriber, patient, and specialty pharmacy before resubmitting. Contact manufacturer at 1-866-923-1954 for assistance.

Are generic and brand Sabril covered equally? Most Blue Cross plans prefer generic vigabatrin (lower tier, lower copay). Brand Sabril may require additional justification.

How often do I need to renew authorization? Typically every 3-12 months depending on indication. Infantile spasms: shorter renewal periods (2-4 weeks initially) to assess benefit. Refractory epilepsy: longer periods if responding.

What if my vision changes during treatment? Report immediately to prescriber and ophthalmologist. Vision changes may require treatment discontinuation per FDA labeling and REMS requirements.

When to Get Help

If you're struggling with denials or appeals, consider professional assistance:

  • Counterforce Health: Specializes in turning insurance denials into evidence-backed appeals for specialty medications like vigabatrin
  • Texas Department of Insurance: 1-800-252-3439 for process violations or guidance
  • Office of Public Insurance Counsel: 1-877-611-6742 for consumer questions
  • Disability Rights Texas: Assistance with Medicaid fair hearings and complex cases

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by specific Blue Cross Blue Shield plan. Always consult your healthcare provider for medical decisions and verify current requirements with your insurance plan. For official Texas insurance regulations and appeal rights, contact the Texas Department of Insurance.

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