By Counterforce Health Team in Uplizna (inebilizumab) —

The Requirements Checklist to Get Uplizna (inebilizumab) Covered by Blue Cross Blue Shield in Texas: Complete Prior Authorization Guide

Answer Box: Getting Uplizna Covered by BCBS Texas

Uplizna (inebilizumab) requires prior authorization from Blue Cross Blue Shield of Texas for both NMOSD and IgG4-RD. The fastest path to approval: (1) Confirm AQP4-IgG positive status via cell-based assay for NMOSD or histologic confirmation for IgG4-RD, (2) Document failed conventional therapies with dates and outcomes, (3) Submit complete prior authorization through Blue Approvr or Availity with neurologist's medical necessity letter. Start today by gathering your lab reports and treatment history. Appeals must be filed within 180 days if denied, with external review available through Texas Department of Insurance.

Table of Contents

Who Should Use This Checklist

This comprehensive guide is designed for patients, caregivers, and healthcare providers navigating Uplizna coverage with Blue Cross Blue Shield of Texas. You'll benefit from this checklist if you:

  • Have been diagnosed with AQP4-positive NMOSD or IgG4-related disease
  • Received a denial for Uplizna and need to appeal
  • Are preparing an initial prior authorization request
  • Want to avoid common submission errors that delay approval

Expected outcome: With proper documentation following this checklist, most medically appropriate requests receive approval within 3-5 business days. If denied, Texas law provides strong appeal rights with binding external review options.

Member & Plan Basics

Coverage Verification Requirements

Before starting your prior authorization, confirm these essential details:

Requirement What to Verify Where to Find It
Active Coverage Member ID, effective dates BCBS Texas member portal
Plan Type Commercial, Medicare Advantage, Medicaid Insurance card, benefits summary
Medical vs. Pharmacy Benefit Uplizna coverage location Call member services number on card
Deductible Status Amount met, remaining balance Online account or member services
Specialty Drug Authorization PA requirement confirmed BCBS Texas PA code lists
Note: Uplizna requires prior authorization across all BCBS Texas plan types, including HealthSelect and Consumer Directed HealthSelect plans.

Clinical Criteria Requirements

For NMOSD (Neuromyelitis Optica Spectrum Disorder)

Primary Requirements:

  • Diagnosis: Confirmed NMOSD per 2015 International Panel criteria
  • AQP4-IgG Status: Positive via cell-based assay (ELISA may not meet requirements)
  • Age: 18 years or older
  • Specialist Involvement: Neurologist with NMOSD experience
  • Relapse History: At least 2 relapses in past 24 months, with ≥1 in past 12 months
  • Disability Level: EDSS score ≤8.0
  • Safety Screening: Hepatitis B testing completed

Primary Requirements:

  • Diagnosis: Histologically confirmed IgG4-RD with organ involvement
  • Documentation: Clinical and pathological evidence
  • Prior Therapy: Evidence of inadequate response to conventional treatments
  • Specialist Care: Rheumatologist or appropriate specialist involvement
From our advocates: "We've seen the highest approval rates when neurologists include specific AQP4-IgG titer values from cell-based assays rather than just stating 'positive.' The more precise the lab data, the stronger the case becomes during review."

Coding & Billing Requirements

Essential Medical Codes

Code Type Code Description Notes
ICD-10 G36.0 Neuromyelitis optica (NMOSD) Primary diagnosis code
ICD-10 D89.84 IgG4-related disease For new indication
HCPCS J1823 Inebilizumab-cdon, 1 mg Each unit = 1 mg
NDC 75987-0150-03 11-digit NDC number Required for billing
CPT 96365 IV infusion, initial hour Administration code
CPT 96366 IV infusion, additional hour If infusion >1 hour

Typical Dosing: 300 mg per dose = 300 units of J1823

Billing Requirements

  • Submit ICD-10, HCPCS J1823, and infusion CPT codes together
  • Include NDC number and units for Medicaid plans
  • Verify site-of-care requirements with your specific plan

Documentation Packet

Provider Note Elements

Your neurologist's documentation must include:

Clinical History:

  • Initial symptom presentation and timeline
  • Diagnostic workup including MRI findings
  • AQP4-IgG test results with methodology specified
  • Complete neurological examination findings
  • EDSS score assessment

Treatment History:

  • All prior NMOSD treatments with specific details:
    • Medication names and doses
    • Duration of each trial
    • Specific reasons for discontinuation
    • Documented inadequate response or intolerance

Current Status:

  • Recent relapse activity and severity
  • Functional impact and disability progression
  • Current symptoms affecting daily activities

Medical Necessity Letter Components

The neurologist's letter must address:

  1. Clinical Rationale
    • Why Uplizna is medically necessary for this specific patient
    • Evidence base supporting use in NMOSD/IgG4-RD
    • Expected clinical benefits and treatment goals
  2. Alternative Therapy Documentation
    • Specific contraindications to other treatments
    • Previous failures with rituximab, azathioprine, mycophenolate
    • Why step therapy alternatives are inappropriate
  3. Safety Considerations
    • Hepatitis B screening results
    • Infection risk assessment
    • Monitoring plan during treatment

Required Attachments

Essential Documents:

  • Recent clinic notes (last 3-6 months)
  • AQP4-IgG lab report (cell-based assay preferred)
  • MRI reports showing NMOSD-consistent lesions
  • Hepatitis B screening results
  • Documentation of prior therapy failures
  • EDSS assessment scores

Supporting Evidence:

  • Hospital discharge summaries for recent relapses
  • Physical therapy evaluations showing functional impact
  • Ophthalmology reports for optic neuritis episodes

Submission Process

BCBS Texas Submission Methods

Primary Options:

  • Blue Approvr™: Electronic submission platform
  • Availity®: Provider portal for PA requests
  • Phone: Call PA number on member's ID card

For Carelon-Managed Services:

  • Phone: 1-866-455-8415
  • Online: Carelon Insights website

Form Requirements

  • Use current, Texas-specific forms to avoid delays
  • Ensure all provider information matches BCBS records:
    • Current practice name and address
    • National Provider Identifier (NPI)
    • Tax Identification Number (TIN)
  • Include member information exactly as shown on insurance card

Submission Best Practices

Tip: Electronic submissions through Blue Approvr or Availity process faster than fax submissions and provide immediate confirmation of receipt.

Timeline Expectations:

  • Standard PA Decision: Within 3 business days
  • Expedited PA: Within 24 hours (requires medical urgency justification)

Specialty Pharmacy Requirements

BCBS Texas Preferred Network

Uplizna must be obtained through BCBS Texas contracted specialty pharmacies:

Medical Benefit Coverage:

  • Medication delivered to provider's office or infusion center
  • Provider bills only for administration (CPT 96365/96366)
  • Drug cost covered under medical benefit

Key Requirements:

  • Confirm pharmacy is in BCBS Texas specialty network
  • Coordinate delivery timing with infusion appointments
  • Verify proper storage and handling capabilities

Preferred Specialty Pharmacies:

After Submission

Tracking Your Request

Confirmation Steps:

  1. Record confirmation number from submission
  2. Note submission date and method used
  3. Set calendar reminder for follow-up (day 3 for standard requests)
  4. Keep copies of all submitted documents

Status Check Schedule:

  • Day 3: Check decision status if no response received
  • Day 5: Contact member services if still pending
  • Day 7: Escalate to provider relations if unresolved

What to Record:

  • Case reference numbers
  • Names of representatives spoken with
  • Dates and times of all communications
  • Any additional information requested

Common Denial Pitfalls

Top 5 Denial Reasons & Prevention

Denial Reason How to Prevent Required Action
Not AQP4-positive Submit cell-based assay results Include specific titer values and methodology
Insufficient specialist involvement Neurologist must be primary prescriber Provide specialist credentials and NMOSD experience
Missing step therapy Document all prior treatments Include dates, doses, duration, and failure reasons
Incomplete safety screening Submit all required lab work Include hepatitis B panel and TB screening
Site of care issues Verify infusion center capabilities Confirm in-network status and proper licensing

Critical Success Factors:

  • Use precise medical terminology throughout documentation
  • Include specific dates for all treatments and assessments
  • Provide quantitative measures (EDSS scores, relapse frequency)
  • Reference FDA labeling and clinical guidelines where appropriate
  • Ensure all forms are completely filled out with no blank fields

Appeals Process for BCBS Texas

If your initial request is denied, Texas law provides strong appeal rights:

Internal Appeal Process

Timeline: Must file within 180 days of denial notice

Submission Requirements:

  • Complete BCBS Texas appeal form
  • Copy of original denial letter
  • Updated medical necessity letter addressing denial reasons
  • Any new clinical information or test results
  • Supporting literature or guidelines

Review Timeline:

  • Standard Appeal: Decision within 7-30 days
  • Expedited Appeal: Decision within 1-3 business days (if delay threatens health)

External Review (IRO)

If internal appeal is denied, you can request binding external review:

Eligibility: Available for medical necessity denials on state-regulated plans

Timeline: Must request within 4 months (120 days) of final internal denial

Process:

  • Standard External Review: Decision within 20 days
  • Expedited External Review: Decision within 5 days for urgent cases
  • Cost: Free to patient; BCBS pays review fees

Contact Information:

  • Texas Department of Insurance IRO Program: 1-866-554-4926
  • TDI Consumer Help: 1-800-252-3439

For patients seeking expert assistance with insurance appeals, Counterforce Health specializes in turning denials into targeted, evidence-backed appeals by analyzing denial letters and plan policies to craft point-by-point rebuttals aligned with payer requirements.

Quick Reference Checklist

Before You Start

  • Verify active BCBS Texas coverage
  • Confirm Uplizna requires prior authorization
  • Gather insurance card and member ID
  • Collect all medical records and lab results

Clinical Requirements

  • AQP4-IgG positive (cell-based assay) OR IgG4-RD confirmed
  • Neurologist/specialist involved in care
  • Prior therapy failures documented with dates
  • Safety screening completed (Hepatitis B, TB)
  • Recent EDSS score available

Documentation Package

  • Medical necessity letter from specialist
  • Recent clinic notes (3-6 months)
  • Lab reports (AQP4-IgG, safety screening)
  • MRI reports showing disease activity
  • Prior treatment documentation
  • Current symptom/disability assessment

Submission

  • Use current BCBS Texas forms
  • Submit via Blue Approvr or Availity (preferred)
  • Include all required attachments
  • Record confirmation number and date
  • Set follow-up reminder for day 3

FAQ

How long does BCBS Texas prior authorization take for Uplizna? Standard requests receive decisions within 3 business days. Expedited requests for urgent medical situations are decided within 24 hours.

What if Uplizna is not on my plan's formulary? Uplizna requires prior authorization but is typically covered under the medical benefit for IV administration. Non-formulary status can be appealed with medical necessity documentation.

Can I request an expedited review? Yes, if waiting for standard review would seriously jeopardize your health. Include medical justification for urgency with your request.

Does step therapy apply if I've tried treatments outside Texas? Yes, prior treatment history from any location counts toward step therapy requirements. Provide complete documentation of all previous therapies.

What happens if my appeal is denied? You can request external review through Texas Department of Insurance within 4 months. This independent review is binding on BCBS Texas and free to patients.

How much does Uplizna cost without insurance? List price is approximately $140,000 per dose. Year one (3 doses) costs around $420,000, with subsequent years (2 doses annually) costing about $280,000.

Can I use manufacturer assistance programs? Yes, Amgen offers patient support programs. Visit Amgen By Your Side or call their patient support line for eligibility information.

What if I have an ERISA self-funded plan? Self-funded employer plans follow federal appeal rules rather than Texas state processes. Check with your HR department for specific appeal procedures.

This guide is for informational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual medical circumstances and specific plan terms. For personalized assistance, consult with your healthcare provider and insurance representative.

Additional Texas Resources:

For comprehensive support with complex prior authorizations and appeals, Counterforce Health helps patients and providers navigate insurance denials with evidence-backed appeal strategies tailored to specific payer requirements.

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