By Counterforce Health Team in Gattex (teduglutide) —

The Complete Requirements Checklist to Get Gattex (teduglutide) Covered by Blue Cross Blue Shield in California

Answer Box: Fast Track to Gattex Coverage

Blue Shield of California requires prior authorization for Gattex (teduglutide) for patients with parenteral-nutrition-dependent short bowel syndrome. Submit PA through the Provider Connection portal with SBS diagnosis confirmation, PN dependence documentation, and clinical evidence. If denied, file an internal appeal within plan timelines, then escalate to California's Independent Medical Review (IMR) through the DMHC for binding external review. Start today: Verify your Blue Shield plan type and download the current prior authorization list.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Billing Information
  5. Documentation Packet Essentials
  6. Submission Process
  7. Specialty Pharmacy Network
  8. After Submission: What to Track
  9. Common Denial Reasons & Solutions
  10. California Appeals Process
  11. Quick Reference Checklist

Who Should Use This Checklist

This guide is designed for California patients with short bowel syndrome (SBS) who need Gattex (teduglutide) coverage through Blue Shield of California, as well as their healthcare providers and caregivers. Use this checklist if you're:

  • Recently diagnosed with SBS requiring parenteral nutrition support
  • Transitioning from another insurer to Blue Shield of California
  • Facing a Gattex prior authorization denial
  • Starting treatment with a new gastroenterologist or specialty clinic

Expected outcome: Following this checklist increases your chances of first-time approval and reduces delays in accessing this critical medication for SBS management.

Member & Plan Basics

Before starting your prior authorization request, verify these fundamental requirements:

Coverage Verification

  • Active Blue Shield of California membership (check your member ID card)
  • Plan type confirmed: Commercial, Medicare Advantage, or Medi-Cal (Promise Health Plan)
  • Benefits verification: Call the number on your ID card to confirm specialty drug coverage

Key Plan Details

Requirement What to Verify Where to Check
Prior authorization needed Gattex on PA list BSC Prior Auth List PDF
Formulary status Tier placement/coverage Provider Connection portal
Specialty pharmacy requirement Limited distribution drug Member services or provider portal
Deductible status Medical vs. pharmacy benefit Your specific plan documents
Note: Blue Shield of California routinely updates PA requirements. The January 1, 2026 prior authorization list shows continued PA requirements for Gattex across multiple plan types.

Clinical Criteria Requirements

Blue Shield of California's medical policy for teduglutide requires specific clinical documentation:

Primary Indication

  • Confirmed diagnosis: Short bowel syndrome with parenteral nutrition dependence
  • ICD-10 code: K91.2 (Postsurgical malabsorption, not elsewhere classified) or related SBS codes
  • Documentation required: Provider office chart notes, lab results, or clinical evidence verifying all criteria

Clinical Evidence Checklist

✓ Anatomical confirmation: Surgical reports showing bowel resection or imaging confirming short bowel length
✓ Functional evidence: Net fluid/electrolyte malabsorption documented
✓ Nutritional dependence: Current parenteral nutrition requirements with volume/calorie documentation
✓ Optimization attempts: Evidence of enteral feeding trials, dietary modifications, or other supportive measures
✓ Baseline assessments: Weight trends, albumin levels, nutritional status evaluation

Age and Dosing Requirements

  • Approved for: Adults and pediatric patients ≥1 year with SBS
  • Standard dosing: 0.05 mg/kg/day subcutaneously after 4-week dose escalation
  • Monitoring requirements: Colonoscopy within 6 months prior to initiation and every 6 months during treatment

Coding & Billing Information

Proper coding ensures clean claims processing and reduces denials:

HCPCS/Billing Codes

  • Primary codes: J3490 (unclassified drugs) or J3590 (unclassified biologics)
  • Alternative: C9399 for unclassified drugs or biologicals (payer-specific acceptance)
  • NDC number: 68875-0102-1 (30 drug vial kits)

ICD-10 Diagnosis Codes

  • K91.2: Postsurgical malabsorption, not elsewhere classified
  • K59.1: Diarrhea, unspecified (if applicable)
  • Z99.2: Dependence on renal dialysis (for PN dependence documentation)
Tip: Verify current billing codes with Blue Shield of California, as Gattex lacks a specific J-code and coding practices may evolve.

Documentation Packet Essentials

Provider Medical Necessity Letter Components

Your prescribing physician should include these elements in the medical necessity letter:

  1. Patient identification: Name, DOB, member ID, diagnosis
  2. Clinical history: SBS etiology, surgical history, current symptoms
  3. Objective evidence: Recent labs (albumin, nutritional markers), imaging, weight trends
  4. Treatment history: Prior therapies attempted, enteral feeding trials, outcomes
  5. Current status: Parenteral nutrition requirements, volumes, complications
  6. Rationale for Gattex: Why teduglutide is medically necessary for this patient
  7. Monitoring plan: Follow-up schedule, safety assessments, treatment goals

Required Attachments

  • Recent office visit notes (within 30 days)
  • Surgical reports documenting bowel resection
  • Parenteral nutrition logs with volumes and composition
  • Laboratory results (albumin, nutritional panels)
  • Previous treatment failure documentation
  • Colonoscopy reports (if applicable)

Submission Process

Primary Submission Method

Blue Shield of California Provider Connection Portal:

  • Website: www.blueshieldca.com/provider
  • Navigate to: Authorizations tab → Submit new request
  • Upload: All required documentation as PDF attachments
  • Track: Request status and communications

Alternative Submission Options

  • Phone: Customer service number on member ID card
  • Fax: Provider-specific fax numbers (verify current number through portal)

Timeline Expectations

  • Standard review: 24-72 hours for most requests
  • Expedited review: Available for urgent clinical situations
  • Additional information requests: May extend timeline by 5-10 business days
Important: Blue Shield of California has been working to reduce prior authorization requirements, with targets for January 1, 2026 reductions in certain categories.

Specialty Pharmacy Network

Gattex is a limited distribution drug requiring specific specialty pharmacy vendors:

Preferred Blue Shield Specialty Pharmacies

  • CVS Specialty (primary vendor for many plans)
  • Accredo (available for certain benefit designs)
  • AllianceRx Walgreens Pharmacy (select plans)

Coordination Process

  1. Prior authorization approval must be obtained first
  2. Prescription routing: Doctor sends prescription to designated specialty pharmacy
  3. Insurance verification: Specialty pharmacy coordinates benefits and copay assistance
  4. Home delivery: Most specialty pharmacies offer refrigerated shipping for Gattex

Counterforce Health specializes in navigating these complex specialty pharmacy networks and can help ensure your prescription reaches the right vendor with proper prior authorization documentation.

After Submission: What to Track

Documentation to Maintain

  • Confirmation numbers from portal submissions
  • Reference numbers from phone calls
  • Email confirmations and timestamps
  • Additional information requests and your responses

Follow-Up Schedule

  • Day 3: Check portal for status updates or requests for additional information
  • Day 7: Call provider services if no initial response
  • Day 14: Escalate to supervisor if standard timeline exceeded
  • Day 21: Consider expedited review request if clinically appropriate

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
"No documented SBS with PN dependence" Submit surgical reports, current PN logs Operative notes, daily PN volumes/composition
"Inadequate baseline PN documentation" Provide detailed nutrition records 30-90 day PN logs, dietitian notes
"Failure to optimize enteral strategies" Document enteral feeding trials Tube feeding records, tolerance issues, outcomes
"Quantity over limits" Justify dosing based on weight/clinical need Dosing calculations, clinical rationale
"Not medically necessary" Strengthen clinical evidence Additional specialist opinions, guideline citations

From Our Advocates

In our experience helping patients navigate specialty drug approvals, the most successful Gattex cases include comprehensive parenteral nutrition logs showing both current dependence and previous attempts at enteral optimization. Plans want to see that less expensive alternatives have been thoroughly explored before approving this high-cost therapy.

California Appeals Process

If your initial prior authorization is denied, California offers robust appeal rights:

Internal Appeals (Blue Shield)

  • Timeline: Submit within plan-specified deadline (typically 365 days)
  • Standard appeals: 30 calendar days for resolution
  • Expedited appeals: 72 hours for urgent situations requiring physician certification
  • Submission: Through Provider Connection portal or member services

Independent Medical Review (IMR)

California's external review process provides binding decisions:

  • Eligibility: After Blue Shield upholds denial or fails to decide within 30 days
  • Filing deadline: Within 6 months of plan's final decision
  • Timeline: 30 days for standard IMR, 3 days for expedited
  • Process: DMHC online application
  • Cost: No fee to patients; insurers pay review costs

Success Strategies for IMR

  1. Gather strong clinical evidence: Peer-reviewed studies on teduglutide efficacy
  2. Document medical necessity: Clear connection between SBS severity and treatment need
  3. Include expert opinions: Specialist letters supporting Gattex appropriateness
  4. Reference guidelines: FDA labeling, gastroenterology society recommendations

Organizations like Counterforce Health specialize in preparing evidence-based appeals that align with California's IMR requirements and have experience with complex specialty drug cases.

Quick Reference Checklist

Before You Start

☐ Active Blue Shield of California coverage verified
☐ Member ID card and policy information available
☐ Confirmed SBS diagnosis with ICD-10 code
☐ Current parenteral nutrition requirements documented

Clinical Documentation

☐ Medical necessity letter from prescribing physician
☐ Surgical reports confirming short bowel syndrome
☐ Parenteral nutrition logs (30-90 days)
☐ Laboratory results (albumin, nutritional markers)
☐ Evidence of enteral feeding optimization attempts
☐ Recent office visit notes (within 30 days)

Submission Process

☐ Prior authorization submitted via Provider Connection portal
☐ All required attachments uploaded as PDFs
☐ Confirmation number recorded
☐ Specialty pharmacy coordination initiated

Follow-Up Actions

☐ Status checked at 3, 7, and 14-day intervals
☐ Additional information requests responded to promptly
☐ Appeal preparation begun if initial denial received
☐ IMR application ready if internal appeals unsuccessful

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan benefits and clinical circumstances. Always consult with your healthcare provider and insurance plan for specific coverage determinations. For additional support with complex prior authorizations and appeals, consider consulting with patient advocacy organizations or services like Counterforce Health that specialize in insurance coverage for specialty medications.

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