By Counterforce Health Team in Cresemba (isavuconazole) —

Myths vs. Facts: Getting Cresemba (Isavuconazole) Covered by Blue Cross Blue Shield in Illinois

Answer Box: Getting Cresemba Covered in Illinois

Blue Cross Blue Shield of Illinois requires prior authorization for Cresemba (isavuconazole) with infectious disease specialist consultation. The fastest path to approval: 1) Ensure your ID specialist documents confirmed invasive aspergillosis or mucormycosis with lab evidence, 2) Submit PA request via Availity Essentials with contraindications to voriconazole clearly stated, 3) If denied, file internal appeal within 180 days, then external review within 30 days under Illinois law. Processing takes 15 business days (24 hours if expedited).

Table of Contents

Why Myths About Cresemba Coverage Persist

Cresemba (isavuconazole) coverage myths flourish because invasive fungal infections are rare, expensive to treat, and often require specialized knowledge that general practitioners encounter infrequently. With a wholesale acquisition cost exceeding $1,600 for a typical course, Blue Cross Blue Shield of Illinois maintains strict prior authorization requirements that many patients and even some clinicians misunderstand.

The complexity of antifungal therapy, combined with Blue Cross Blue Shield's varying policies across different plan types, creates fertile ground for misconceptions. When facing a life-threatening infection like invasive aspergillosis or mucormycosis, families often receive conflicting advice from well-meaning sources who may not understand Illinois-specific insurance regulations or current Blue Cross Blue Shield criteria.

Common Myths vs. Facts

Myth 1: "If my infectious disease doctor prescribes Cresemba, Blue Cross Blue Shield must cover it automatically"

Fact: Blue Cross Blue Shield of Illinois requires prior authorization for Cresemba regardless of prescriber specialty. According to BCBS Illinois pharmacy management policies, even infectious disease specialists must submit detailed documentation proving medical necessity, confirmed diagnosis, and contraindications to first-line alternatives like voriconazole.

Myth 2: "I can't get Cresemba covered if voriconazole is available and cheaper"

Fact: You can obtain Cresemba coverage when voriconazole is contraindicated. Common documented contraindications include hepatotoxicity, severe photosensitivity reactions, QTc prolongation, drug interactions with medications like sirolimus or pimozide, or pregnancy (voriconazole is toxic to the fetus). Your infectious disease specialist must document these specific medical reasons in the prior authorization request.

Myth 3: "Blue Cross Blue Shield denies all expensive antifungal medications to save money"

Fact: Blue Cross Blue Shield approves Cresemba when clinical criteria are met. Their utilization management program is designed to ensure appropriate patient selection according to FDA labeling and clinical guidelines, not blanket cost-cutting. Success rates improve significantly with proper documentation of confirmed diagnosis and specialist consultation.

Myth 4: "If my first appeal is denied, there's nothing more I can do"

Fact: Illinois provides robust appeal rights under the Health Carrier External Review Act. After internal appeal denial, you have 30 days to request external review by an independent physician reviewer. According to Illinois Department of Insurance data, external reviews are decided within 5 business days and are binding on the insurer if approved.

Myth 5: "I need to try and fail multiple cheaper antifungals before getting Cresemba"

Fact: Step therapy requirements vary by specific Blue Cross Blue Shield plan, but documented contraindications to first-line therapy can bypass step requirements. If you have medical reasons why voriconazole or amphotericin B cannot be used safely, your infectious disease specialist can request immediate access to Cresemba.

Myth 6: "Generic antifungals are always required first"

Fact: There is no generic version of isavuconazole. The comparison is between different antifungal classes. For invasive aspergillosis, voriconazole is typically first-line, but Cresemba is recognized as an appropriate alternative in major clinical guidelines when voriconazole is contraindicated or not tolerated.

Myth 7: "Blue Cross Blue Shield never covers brand-name medications for rare diseases"

Fact: Blue Cross Blue Shield covers medically necessary brand-name medications when no appropriate alternatives exist or when generic/preferred alternatives are contraindicated. Invasive fungal infections often require specific antifungal agents based on organism susceptibility and patient factors.

Myth 8: "I can't get expedited approval for urgent fungal infections"

Fact: Blue Cross Blue Shield offers expedited prior authorization review (24-72 hours) for urgent medical situations. If delay would seriously jeopardize your health, your physician can request expedited review and, if denied, expedited internal appeal and external review under Illinois law.

What Actually Influences Approval

Clinical Documentation Requirements

Blue Cross Blue Shield approval depends on specific clinical criteria being met and properly documented:

Confirmed Diagnosis: Laboratory evidence of invasive aspergillosis (ICD-10: B44.0) or mucormycosis (ICD-10: B46.0-B46.9) through culture, pathology, or biomarker testing like galactomannan or beta-D-glucan.

Specialist Involvement: The prescriber must be an infectious disease specialist or be in active consultation with an ID specialist, transplant physician, or oncologist, per BCBS medical policies.

Alternative Therapy Assessment: Clear documentation of why voriconazole (first-line for aspergillosis) cannot be used, including specific contraindications, previous treatment failures, or intolerance.

Submission Process and Timing

Electronic Submission: Use Availity Essentials as the preferred portal for prior authorization requests. Alternative submission through BlueApprovR may be available for certain commercial non-HMO plans.

Processing Timelines: Standard requests must be processed within 15 business days maximum. Expedited requests for urgent medical situations are processed within 24-72 hours.

Documentation Completeness: Include all supporting materials with initial submission to avoid delays: lab results, imaging studies, specialist consultation notes, and detailed treatment rationale.

Avoid These Critical Mistakes

Mistake 1: Submitting Incomplete Prior Authorization Requests

The Fix: Ensure your infectious disease specialist includes all required elements: confirmed diagnosis with ICD-10 codes, laboratory evidence, imaging results, detailed rationale for Cresemba over alternatives, proposed treatment duration, and liver function monitoring plan.

Mistake 2: Not Documenting Voriconazole Contraindications

The Fix: Specifically document medical reasons why voriconazole cannot be used. Generic statements like "patient cannot tolerate other antifungals" are insufficient. Detail specific contraindications such as hepatotoxicity, drug interactions, or pregnancy.

Mistake 3: Missing Illinois Appeal Deadlines

The Fix: Illinois has a shorter external review deadline than many states. You must request external review within 30 days of your final internal appeal denial, not the 4-month window available in some other states.

Mistake 4: Not Using Available Support Resources

The Fix: Contact the Illinois Department of Insurance Office of Consumer Health Insurance at 877-527-9431 for help with appeals. The Illinois Attorney General's Health Care Helpline (1-877-305-5145) can also assist with complex cases.

Mistake 5: Accepting Initial Denials Without Appeal

The Fix: Studies show up to 80% of appeals can be successful, yet less than 1% of denied claims are ever appealed. If your clinical situation meets medical necessity criteria, pursue the appeal process rather than accepting the initial denial.

From our advocates: "We've seen many patients give up after the first denial, thinking that's the end of the road. In one composite case, a patient with invasive aspergillosis was initially denied Cresemba coverage, but after properly documenting voriconazole-induced hepatotoxicity and submitting a comprehensive appeal with specialist support, coverage was approved within two weeks. The key was having the infectious disease specialist clearly articulate why alternatives weren't medically appropriate."

Quick Action Plan: Three Steps to Take Today

Step 1: Verify Your Coverage and Gather Documentation

  • Call Blue Cross Blue Shield member services to confirm your current coverage status and prior authorization requirements
  • Request copies of all relevant medical records: lab results showing fungal infection, imaging studies, specialist consultation notes
  • Obtain your complete medication history and documentation of any previous antifungal treatments

Step 2: Connect with Your Infectious Disease Specialist

  • Schedule an appointment to discuss Cresemba coverage requirements specifically
  • Ask your ID specialist to document contraindications to voriconazole in detail
  • Request that they prepare a comprehensive medical necessity letter addressing Blue Cross Blue Shield's clinical criteria

Step 3: Submit Prior Authorization Through Proper Channels

  • Use Availity Essentials for electronic submission
  • Include all supporting documentation with your initial request
  • Record your confirmation number and track the status through the portal

Appeals Process in Illinois

Internal Appeal (First Level)

Timeline: File within 180 days of denial; decision within 15 business days (24 hours if expedited)

How to Submit: Written appeal via Blue Cross Blue Shield member portal, fax, or certified mail

Required Documentation: Original denial letter, medical records supporting medical necessity, specialist consultation notes

External Review (Second Level)

Timeline: File within 30 days of internal appeal denial; decision within 5 business days of IRO receiving all materials

How to Submit: Contact Illinois Department of Insurance or use forms provided by Blue Cross Blue Shield

Review Process: Independent physician reviewer with relevant specialty expertise makes binding decision

When facing a challenging insurance denial for a critical medication like Cresemba, having expert support can make the difference between approval and continued delays. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific denial basis and craft point-by-point rebuttals aligned to each payer's own rules.

Resources and Support

Illinois State Resources

Blue Cross Blue Shield Resources

Financial Assistance

  • Cresemba Patient Support: Astellas Patient Assistance
  • Illinois Pharmaceutical Assistance Programs: Contact Illinois Department of Healthcare and Family Services
  • Foundation Grants: Patient Access Network Foundation and similar organizations may provide copay assistance

Clinical Guidelines and References

  • FDA Prescribing Information: Cresemba Label (FDA)
  • Infectious Diseases Society of America Guidelines: Available through IDSA website
  • Blue Cross Blue Shield Medical Policies: Accessible through provider portals with policy numbers

For complex cases requiring specialized support in navigating insurance appeals, Counterforce Health provides comprehensive assistance in developing evidence-based appeal strategies that address payer-specific requirements and improve approval success rates.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare providers and insurance company for guidance specific to your situation. Coverage policies and requirements may vary by specific Blue Cross Blue Shield plan and can change over time.

Sources & Further Reading

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