Topic

Blue Cross Blue Shield (BCBS Association)

A collection of 1127 issues

Myths vs. Facts: Getting Orkambi (lumacaftor/ivacaftor) Covered by Blue Cross Blue Shield in New Jersey

Answer Box: Getting Orkambi covered by Blue Cross Blue Shield in New Jersey requires prior authorization with documented F508del homozygous mutation, CF specialist prescription, and baseline clinical data. If denied, you have internal appeal rights plus New Jersey's Independent Health Care Appeals Program (IHCAP) through Maximus Federal within

How to Get Lutathera (Lutetium Lu-177 Dotatate) Covered by Blue Cross Blue Shield in North Carolina: Complete Guide with Forms and Appeals

Answer Box: Getting Lutathera Covered by Blue Cross Blue Shield in North Carolina Blue Cross Blue Shield of North Carolina covers Lutathera (lutetium Lu-177 dotatate) for somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors when medical necessity criteria are met. Fastest path to approval: Submit prior authorization with complete documentation including SSTR-positive imaging,

Renewing Hemgenix (etranacogene dezaparvovec) Approval with Blue Cross Blue Shield in Pennsylvania: Annual Requirements and Timeline

Answer Box: Renewing Hemgenix Coverage in Pennsylvania Hemgenix (etranacogene dezaparvovec) is a one-time gene therapy, but Blue Cross Blue Shield plans in Pennsylvania may require annual clinical documentation for outcomes monitoring and related services coverage. Start renewal submissions 60-90 days before your authorization period expires. Submit updated Factor IX levels,

How to Get Revlimid (lenalidomide) Covered by Blue Cross Blue Shield of Texas: Prior Authorization Forms, Appeals Timeline & Scripts

Answer Box: Getting Revlimid Covered by BCBS of Texas Blue Cross Blue Shield of Texas requires prior authorization for Revlimid (lenalidomide) across all 2024-2025 formularies. The fastest path to approval: (1) Verify your plan's specific drug list and PA requirements via the BCBS Texas prescription drug portal, (2)

How to Get Gamifant (Emapalumab-lzsg) Covered by Blue Cross Blue Shield of Texas: Complete Guide with Forms, Appeals, and IRO Process

Answer Box: Getting Gamifant Covered in Texas Blue Cross Blue Shield of Texas requires prior authorization for Gamifant (emapalumab-lzsg), with approval based on documented primary HLH meeting HLH-2004 criteria and failure/intolerance of conventional therapy. Submit via the BCBSTX provider portal with complete HLH diagnostic workup. If denied, Texas law

How to Get Translarna (Ataluren) Covered by Blue Cross Blue Shield in Georgia: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Translarna Covered in Georgia Translarna (ataluren) requires prior authorization from Blue Cross Blue Shield of Georgia (Anthem BCBS). The fastest path: (1) Confirm your genetic testing shows a nonsense mutation in the DMD gene, (2) Have your neurologist submit a comprehensive PA request through Anthem's

How to Get Daybue (trofinetide) Covered by Blue Cross Blue Shield of Michigan: Complete Forms, Appeals & Timeline Guide

Answer Box: Getting Daybue Covered by BCBS Michigan Daybue (trofinetide) requires prior authorization from Blue Cross Blue Shield of Michigan. The fastest path: 1) Verify your plan type and confirm Daybue isn't excluded, 2) Have your neurologist/specialist submit a PA request with confirmed Rett syndrome diagnosis, genetic

How to Get Ultomiris (Ravulizumab) Covered by Blue Cross Blue Shield in Michigan: Prior Authorization Forms, Timelines, and Appeals Guide

Answer Box: Quick Path to Ultomiris Approval in Michigan Blue Cross Blue Shield of Michigan requires prior authorization for Ultomiris (ravulizumab) under the medical benefit, with new step therapy requirements as of 2024. For commercial members, you must try an alternative therapy first; Medicare Advantage members need rituximab biosimilar trial

Getting Signifor LAR (Pasireotide) Covered by Blue Cross Blue Shield in Washington: Complete 2025 Coding, Prior Auth & Appeals Guide

Answer Box: Quick Path to Coverage To get Signifor LAR covered by Blue Cross Blue Shield in Washington: First, identify your specific carrier (Premera Blue Cross or Regence BlueShield). Submit prior authorization using ICD-10 code E24.0 (Cushing's disease) or E22.0 (acromegaly), HCPCS J2502 for billing, and

How to Get Therakos CELLEX Photopheresis Covered by Blue Cross Blue Shield in New York: Complete Prior Authorization and Appeals Guide

Answer Box: Your Fast Track to Coverage Therakos CELLEX photopheresis is covered by Blue Cross Blue Shield plans in New York for CTCL and steroid-refractory GVHD when medical necessity criteria are met. The fastest path: have your hematologist/oncologist or dermatologist submit prior authorization with complete staging documentation, steroid-refractory evidence