Topic

Blue Cross Blue Shield (BCBS Association)

A collection of 1123 issues

How to Get Opfolda (miglustat) Covered by Blue Cross Blue Shield North Carolina: Complete Appeals Guide with Forms and Timelines

Answer Box: Getting Opfolda Covered by Blue Cross Blue Shield NC Opfolda (miglustat) requires prior authorization from Blue Cross Blue Shield North Carolina and must be used with Pombiliti for adult LOPD patients ≥40 kg who haven't improved on standard ERT for ≥1 year. First step today: Call

How to Get Somatuline Depot (lanreotide) Covered by Blue Cross Blue Shield in Ohio: Prior Authorization Forms, Appeals, and Timeline Guide

Answer Box: Getting Somatuline Depot Covered in Ohio Blue Cross Blue Shield (BCBS) plans in Ohio typically require prior authorization for Somatuline Depot (lanreotide) with specific criteria for acromegaly, GEP-NETs, and carcinoid syndrome. Most plans limit coverage to one syringe per 28 days (maximum 120 mg every 4 weeks) and

Getting Filsuvez (Birch Triterpenes Topical Gel) Covered by Blue Cross Blue Shield in Georgia: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Filsuvez Covered by Blue Cross Blue Shield in Georgia Eligibility: Filsuvez requires prior authorization for junctional or dystrophic epidermolysis bullosa patients ≥6 months with open wounds ≥21 days old. Fastest path: Submit complete PA with genetic confirmation, specialist attestation, and documented failed standard wound care. First step

How to Get Tegsedi (Inotersen) Covered by Blue Cross Blue Shield in New Jersey: Complete Prior Authorization and Appeal Guide

Quick Answer: Getting Tegsedi Covered by Blue Cross Blue Shield in New Jersey Tegsedi (inotersen) requires prior authorization from Blue Cross Blue Shield plans in New Jersey, typically as a non-preferred specialty drug. To get coverage: (1) Your neurologist submits a PA request with hATTR polyneuropathy diagnosis, genetic testing, and

Blue Cross Blue Shield Michigan's Coverage Criteria for Pyrukynd (mitapivat): What Counts as "Medically Necessary"?

Answer Box: Getting Pyrukynd Covered in Michigan Blue Cross Blue Shield of Michigan requires prior authorization for Pyrukynd (mitapivat), typically with these three key steps: (1) Confirmed PKLR gene variants proving pyruvate kinase deficiency, (2) Clinical severity documentation (hemoglobin ≤10 g/dL or ≥6 transfusions in 12 months), and (3)

How to Get Helixate (Antihemophilic Factor, rFVIII) Covered by Blue Cross Blue Shield in Pennsylvania: Complete Timeline and Appeals Guide

Answer Box: Getting Helixate Covered in Pennsylvania Important Update: Helixate NexGen and related Kogenate FS have been discontinued by Bayer. Blue Cross Blue Shield Pennsylvania plans now require prior authorization for alternative factor VIII products like Kovaltry, Advate, or Jivi. The fastest path to approval: (1) Have your hematologist submit

The Requirements Checklist to Get Raxone (Idebenone) Covered by Blue Cross Blue Shield of Illinois

Answer Box Getting Raxone (idebenone) covered by Blue Cross Blue Shield of Illinois requires a formulary exception plus prior authorization since it's not FDA-approved in the U.S. Your fastest path: (1) Have your prescriber submit a pharmacy PA request through MyPrime with genetic testing confirming LHON and

How to Get Vigabatrin (Sabril) Covered by Blue Cross Blue Shield in Illinois: Complete REMS Guide and Appeal Process

Quick Answer: Blue Cross Blue Shield Illinois requires prior authorization for vigabatrin (Sabril), complete REMS enrollment, and vision monitoring documentation. Start the PA process 30-45 days before your current authorization expires. If denied, you have 60 days to file an internal appeal, then 30 days for external review through the

How to Get Elevidys Covered by Blue Cross Blue Shield in Pennsylvania: Prior Authorization Guide with Appeals Process

Answer Box: To get Elevidys covered by Blue Cross Blue Shield in Pennsylvania, you need: 1) Confirmed DMD genetic testing showing pathogenic mutation, 2) Age ≥4 years with negative anti-AAVrh74 antibodies, 3) Prior authorization through your BCBS plan's electronic portal (Availity for Highmark, IBX portal for Independence). Most

How to Get Lamzede (velmanase alfa-tycv) Covered by Blue Cross Blue Shield in Pennsylvania: Prior Authorization Guide

Quick Answer: Blue Cross Blue Shield requires prior authorization for Lamzede (velmanase alfa-tycv) in Pennsylvania. You'll need confirmed alpha-mannosidosis diagnosis with enzyme activity below 11% of normal, documentation of non-CNS manifestations, and agreement to monitor for infusion reactions. If denied, Pennsylvania's new external review program overturns