By Counterforce Health Team in Tavneos (avacopan) —

The Requirements Checklist to Get Tavneos (avacopan) Covered by Blue Cross Blue Shield in Michigan

Answer Box: Getting Tavneos Covered by BCBS Michigan

To get Tavneos (avacopan) covered by Blue Cross Blue Shield of Michigan, you'll need: (1) A diagnosis of severe active ANCA-associated vasculitis (GPA or MPA) with positive ANCA serology, (2) A specialist prescriber (rheumatologist, nephrologist, or pulmonologist), and (3) Documentation that Tavneos will be used alongside standard therapy like rituximab or cyclophosphamide. Submit BCBS Michigan's prior authorization form with complete clinical documentation. If denied, you have 127 days to file an external review with Michigan DIFS. First step today: Contact your specialist to gather ANCA lab results and prior therapy records.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Documentation Essentials
  5. Your Documentation Packet
  6. Submission Process
  7. Specialty Pharmacy Routing
  8. After Submission: What to Expect
  9. Five Common Pitfalls to Avoid
  10. Michigan Appeals Process
  11. Quick Reference Checklist

Who Should Use This Checklist

This guide is designed for Michigan patients with ANCA-associated vasculitis and their healthcare teams seeking coverage for Tavneos (avacopan) through Blue Cross Blue Shield of Michigan (BCBSM). Use this checklist if you:

  • Have been diagnosed with severe active granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA)
  • Are currently covered by any BCBS Michigan plan (commercial, Medicare Plus Blue, or Blue Cross Complete)
  • Need to initiate prior authorization or appeal a denial
  • Want to understand the complete requirements before starting the process

Expected outcome: Following this checklist increases your likelihood of first-time approval and helps avoid common submission errors that delay coverage decisions.

Member & Plan Basics

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

Coverage Verification

  • Active BCBS Michigan membership with prescription drug benefits
  • Specialty drug coverage included in your plan (most BCBS Michigan plans include this)
  • Current member ID card with pharmacy benefit information

Plan Type Considerations

  • Commercial plans: Use standard BCBS Michigan prior authorization forms
  • Medicare Plus Blue: Use the "Global PA Form" for Medicare members
  • Blue Cross Complete (Medicaid): Submit through the NaviNet provider portal

Deductible & Authorization Requirements

  • Tavneos requires prior authorization regardless of your deductible status
  • Annual drug deductibles may apply before coverage begins
  • No quantity limits beyond the standard 180 capsules per 30 days (30 mg twice daily)
Note: BCBS Michigan must respond to prior authorization requests within 15 days for standard requests or 72 hours for expedited requests. If they don't respond within these timeframes, coverage is automatically approved under Michigan law.

Clinical Criteria Requirements

BCBS Michigan follows strict clinical criteria for Tavneos coverage. Your case must meet ALL of these requirements:

Primary Diagnosis

  • Severe active ANCA-associated vasculitis specifically:
    • Granulomatosis with polyangiitis (GPA), or
    • Microscopic polyangiitis (MPA)
  • Confirmed by positive ANCA serology:
    • c-ANCA/PR3-ANCA positive (typically GPA), or
    • p-ANCA/MPO-ANCA positive (typically MPA)

Prescriber Requirements

  • Must be prescribed by a specialist:
    • Rheumatologist
    • Nephrologist
    • Pulmonologist
    • Vascular medicine specialist

Adjunctive Therapy Requirement

Tavneos must be used in combination with standard immunosuppressive therapy:

  • Rituximab plus corticosteroids, or
  • Cyclophosphamide plus corticosteroids
  • Cannot be prescribed as monotherapy

Age and Dosing

  • Patient must be 12 years or older
  • Standard dosing: 30 mg (three 10 mg capsules) twice daily with food
  • Dose reduction to once daily required with strong CYP3A4 inhibitors

Coding & Documentation Essentials

Accurate medical coding prevents automatic denials and supports your medical necessity argument:

ICD-10 Codes

Diagnosis ICD-10 Code When to Use
Granulomatosis with polyangiitis M31.31 Confirmed GPA diagnosis
Microscopic polyangiitis M31.7 Confirmed MPA diagnosis
ANCA vasculitis, unspecified I77.82 ANCA-positive but subtype unclear

HCPCS Coding

  • J8499 (Prescription drug, oral, non-chemotherapeutic, NOS) for Tavneos
  • Include NDC numbers from your prescription for billing accuracy

Supporting Lab Codes

Document ANCA testing with appropriate CPT codes to support your diagnosis:

  • 86037 (Antineutrophilic cytoplasmic antibodies screen)
  • 86038 (ANCA titer)

Your Documentation Packet

Assemble these documents before submitting your prior authorization request:

Medical Necessity Letter Components

Your specialist should include these elements in their letter:

  • Patient demographics and BCBS Michigan member ID
  • Specific diagnosis with ICD-10 code (M31.31 or M31.7)
  • ANCA serology results with dates and values
  • Organ involvement (renal, pulmonary, nervous system, etc.)
  • Prior therapies tried and their outcomes
  • Rationale for Tavneos as adjunctive therapy
  • Planned combination therapy (rituximab or cyclophosphamide)
  • Monitoring plan including liver function tests

Required Attachments

  • Recent ANCA laboratory results
  • Tissue biopsy report (if available)
  • Documentation of prior therapy trials and failures
  • Current laboratory values (CBC, comprehensive metabolic panel, liver function)
  • Disease activity assessment (BVAS score if available)
  • Prescription with NDC numbers
Clinician Corner: Counterforce Health offers evidence-based appeal templates that align clinical documentation with payer-specific requirements, helping providers create stronger medical necessity arguments for complex specialty drugs like Tavneos.

Submission Process

Form Selection

  • Commercial BCBS Michigan: Michigan Prior Authorization Request Form for Prescription Drugs
  • Medicare Plus Blue: Global PA Form
  • Blue Cross Complete: Submit via NaviNet provider portal

Submission Methods

  1. Online portal (preferred): BCBS Michigan provider portal
  2. Fax: Use the fax number specified on the PA form
  3. Mail: Submit to the address listed on the form (verify current address)

Required Form Fields

Incomplete forms cause automatic rejections. Ensure these fields are complete:

  • Patient name exactly as it appears on member ID card
  • Complete member ID number
  • Prescriber NPI number and contact information
  • Specific drug name, strength, and NDC
  • ICD-10 diagnosis code
  • Prescriber signature and date

Expedited Review Criteria

Request expedited review if:

  • Patient has severe organ-threatening disease
  • Delay would cause serious jeopardy to health
  • Include physician certification of medical urgency

Specialty Pharmacy Routing

BCBS Michigan typically requires specialty drugs like Tavneos to be dispensed through contracted specialty pharmacies:

Preferred Vendors

  • Walgreens Specialty Pharmacy (primary specialty vendor for BCBS Michigan)
  • Select contracted retail pharmacies in the network
  • Verify current preferred vendors by calling member services

Transfer Process

  1. Prior authorization approval must be obtained first
  2. Prescription transfer from retail to specialty pharmacy
  3. Insurance verification by specialty pharmacy
  4. Patient enrollment in specialty pharmacy program
  5. Shipment coordination for temperature-controlled delivery

Verification Steps

  • Confirm specialty pharmacy received PA approval
  • Verify correct dosing (30 mg twice daily)
  • Ensure patient has completed enrollment paperwork
  • Schedule delivery for temperature-sensitive medication

After Submission: What to Expect

Timeline Expectations

  • Standard review: 15 business days maximum
  • Expedited review: 72 hours maximum
  • Automatic approval: If BCBS Michigan doesn't respond within statutory timeframes

Status Monitoring

  • Confirmation number: Record when you submit
  • Status checks: Call every 5-7 days if no response
  • Documentation: Keep records of all communications

What to Record

  • Date and method of submission
  • Confirmation or reference numbers
  • Names of representatives you speak with
  • Any additional information requested
  • Decision date and outcome

Five Common Pitfalls to Avoid

Pitfall Why It Causes Denials How to Prevent
Missing ANCA results Can't confirm AAV diagnosis Include recent lab reports with specific antibody titers
Non-specialist prescriber Doesn't meet coverage criteria Ensure rheumatologist, nephrologist, or pulmonologist prescribes
Monotherapy indication FDA requires adjunctive use Document planned combination with rituximab or cyclophosphamide
Incomplete prior therapy history Step therapy not documented List all previous treatments with dates and outcomes
Wrong ICD-10 code Doesn't match covered indications Use M31.31 (GPA) or M31.7 (MPA), not general vasculitis codes

Michigan Appeals Process

If BCBS Michigan denies your Tavneos request, Michigan law provides robust appeal rights:

Internal Appeal (First Level)

  • Timeline: Must file within 180 days of denial
  • Process: Submit appeal letter with additional documentation
  • Decision: BCBS Michigan has 30 days to respond

External Review Through Michigan DIFS

  • Timeline: Must file within 127 days of final internal denial
  • Process: Submit Health Care Request for External Review form (FIS 0018)
  • Decision: Independent medical review within 60 days (72 hours if expedited)

Filing Options

Required Documentation for Appeals

  • Copy of original denial letter
  • Medical records supporting medical necessity
  • Physician certification (if requesting expedited review)
  • Any additional clinical evidence
From Our Advocates: We've seen Michigan external reviews succeed when patients include FDA labeling excerpts showing Tavneos is specifically approved for their diagnosis, combined with clear documentation that standard therapies alone weren't sufficient. The key is connecting your specific clinical situation to the drug's approved indication.

Quick Reference Checklist

Before You Start

  • Active BCBS Michigan coverage verified
  • Specialist prescriber identified (rheum/nephro/pulm)
  • ANCA lab results gathered
  • Prior therapy documentation collected

Clinical Requirements Met

  • Severe active GPA or MPA diagnosis
  • Positive c-ANCA/PR3 or p-ANCA/MPO
  • Planned adjunctive use with standard therapy
  • Patient age 12 or older

Documentation Complete

  • Medical necessity letter written
  • ICD-10 code included (M31.31 or M31.7)
  • ANCA serology attached
  • Prior therapy records attached
  • Current lab values included

Submission Ready

  • Correct PA form selected for plan type
  • All required fields completed
  • Prescriber signature and NPI included
  • Submission method chosen (portal/fax)
  • Confirmation number recorded

Appeals Preparation

  • Michigan DIFS contact information saved
  • 127-day external review deadline noted
  • Appeal documentation organized
  • Counterforce Health resources bookmarked for appeal assistance

Disclaimer: This guide provides general information about insurance coverage requirements and is not medical advice. Coverage decisions depend on your specific plan benefits and clinical circumstances. Consult your healthcare provider for medical guidance and contact BCBS Michigan directly for definitive coverage information.

Need Help with Your Appeal? Counterforce Health specializes in turning insurance denials into successful appeals by creating evidence-backed, payer-specific arguments that align with plan policies and clinical guidelines.

Sources & Further Reading

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