Topic

Blue Cross Blue Shield (BCBS Association)

A collection of 1267 issues

How to Get Palynziq (pegvaliase-pqpz) Covered by Blue Cross Blue Shield in New Jersey: Complete Prior Authorization Guide

Quick Answer: Getting Palynziq Approved in New Jersey Palynziq requires prior authorization from all Blue Cross Blue Shield plans in New Jersey. To get approved, you need: confirmed PKU diagnosis, blood phenylalanine >600 µmol/L, documented failure of diet and sapropterin (Kuvan), REMS program enrollment, and specialist prescription. First

Blue Cross Blue Shield's Coverage Criteria for Zolgensma in Washington: What Counts as "Medically Necessary"?

Answer Box: Getting Zolgensma Covered by Blue Cross Blue Shield in Washington Blue Cross Blue Shield plans in Washington require prior authorization for Zolgensma with strict medical necessity criteria: genetically confirmed SMA with bi-allelic SMN1 mutations, age under 2 years, anti-AAV9 antibody titer ≤1:50, and treatment at an approved

How to Get Kalydeco (ivacaftor) Covered by Blue Cross Blue Shield in Illinois: Prior Authorization, Appeals, and Medical Necessity Requirements

Answer Box: Getting Kalydeco Covered in Illinois Blue Cross Blue Shield of Illinois requires prior authorization for Kalydeco (ivacaftor) based on confirmed cystic fibrosis diagnosis and FDA-approved CFTR mutation. Fastest path: Have your CF specialist submit PA through MyPrime portal with genetic testing, baseline lung function, and mutation documentation. If

How to Renew Xyrem (Sodium Oxybate) Coverage with Blue Cross Blue Shield of Michigan: Timeline, Documentation, and Appeal Guide

Answer Box: Renewing Xyrem Coverage with BCBS Michigan Start your Xyrem renewal 2-4 weeks before your current authorization expires. BCBS Michigan typically approves Xyrem for 6-12 month periods and requires updated clinical documentation showing continued benefit. Submit through your provider's portal or fax with current ESS scores, cataplexy

How to Get Abecma (idecabtagene vicleucel) Covered by Blue Cross Blue Shield of North Carolina: Complete Prior Authorization & Appeals Guide

Answer Box: Getting Abecma Covered by Blue Cross Blue Shield of North Carolina Abecma (idecabtagene vicleucel) requires prior authorization from Blue Cross Blue Shield of North Carolina for adults with relapsed/refractory multiple myeloma after ≥2 prior therapies. Your fastest path to approval: (1) Verify you have a state-regulated BCBS

How to Get Orfadin (Nitisinone) Covered by Blue Cross Blue Shield in Texas: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Orfadin Covered by Blue Cross Blue Shield in Texas Blue Cross Blue Shield of Texas covers Orfadin (nitisinone) as a specialty drug requiring prior authorization for hereditary tyrosinemia type 1 (HT-1). The fastest path to approval: (1) Have your metabolic specialist submit PA with confirmed HT-1 diagnosis

How to Renew Nourianz (Istradefylline) Coverage with Blue Cross Blue Shield in Ohio: Annual Requirements and Timeline

Answer Box: Blue Cross Blue Shield plans in Ohio typically require annual prior authorization renewal for Nourianz (istradefylline), with reapproval depending on documented continued benefit and ongoing use with carbidopa/levodopa. Start the renewal process 30-60 days before expiration by scheduling a follow-up visit to document objective response (reduced "

How to Get Thiola / Thiola EC (tiopronin) Covered by Blue Cross Blue Shield Texas: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Thiola/Thiola EC Covered in Texas Blue Cross Blue Shield of Texas (BCBSTX) covers Thiola/Thiola EC (tiopronin) as a non-preferred specialty drug requiring prior authorization for cystinuria patients. Coverage requires confirmed diagnosis (ICD-10 E72.01), documented failure of conservative therapy (high fluid intake + alkalinization), and specialist

How to Get Defitelio (Defibrotide) Covered by Blue Cross Blue Shield in New Jersey: Complete Timeline Guide and Appeal Templates

Answer Box: Getting Defitelio Covered in New Jersey Defitelio (defibrotide) requires prior authorization from Horizon Blue Cross Blue Shield of New Jersey for hepatic VOD/SOS with organ dysfunction after HSCT. Submit urgent PA requests within 24 hours for life-threatening cases. If denied, file internal appeals within 180 days, then

How Long Does It Take to Get Gamifant (emapalumab-lzsg) Approved by Blue Cross Blue Shield in Georgia? Complete Timeline & Appeals Guide

Answer Box: Gamifant Approval Timeline in Georgia Standard prior authorization: 14-30 days for complete submissions to Blue Cross Blue Shield Georgia (Anthem). Expedited/urgent cases: 72 hours when delay threatens life or health. First step today: Confirm Gamifant is covered under your medical benefit and gather HLH-2004 diagnostic criteria documentation.