By Counterforce Health Team in Acthar Gel (repository corticotropin injection) —

Work With Your Doctor to Get Acthar Gel Covered by Blue Cross Blue Shield in Virginia: Prior Authorization, Appeals, and Medical Necessity Guide

Answer Box: Getting Acthar Gel Covered in Virginia

Blue Cross Blue Shield Virginia requires prior authorization for Acthar Gel (repository corticotropin injection). Your fastest path to approval: (1) Have your specialist document failed corticosteroid trials and medical necessity, (2) Submit comprehensive clinical records through BCBS's provider portal, and (3) If denied, file an external review with Virginia's State Corporation Commission within 120 days. Most approvals occur for infantile spasms in children under 2 or when standard treatments have failed. Start today by requesting your complete treatment history from all providers.

Table of Contents

  1. Set Your Goal: Understanding BCBS Requirements
  2. Prepare for Your Provider Visit
  3. Build Your Evidence Kit
  4. Medical Necessity Letter Structure
  5. Support Your Doctor During Peer-to-Peer Review
  6. Document Everything After Your Visit
  7. Practice Respectful Persistence
  8. Appeals Process in Virginia
  9. Cost Assistance Options
  10. FAQ

Set Your Goal: Understanding BCBS Requirements

Your partnership with your doctor starts with understanding what Blue Cross Blue Shield Virginia needs to approve Acthar Gel. All BCBS plans require prior authorization for this specialty medication, and approval hinges on proving medical necessity through comprehensive documentation.

Coverage Requirements at a Glance

Requirement What It Means Documentation Needed
Specialist Prescription Must be prescribed by or in consultation with appropriate specialist Referral notes, consultation records
Prior Treatment Failures Evidence of failed corticosteroid trials or contraindications Pharmacy records, clinic notes documenting failures
Medical Necessity Clear clinical rationale for Acthar Gel specifically Chart notes, lab results, imaging studies
FDA-Approved Indication Treatment must align with labeled uses Diagnosis codes (ICD-10), clinical documentation
Baseline Monitoring Pre-treatment assessments documented Laboratory results, specialist evaluations

Primary FDA-approved indications where BCBS is most likely to approve include infantile spasms in children under 2 years and multiple sclerosis exacerbations when corticosteroids are contraindicated or ineffective.

Prepare for Your Provider Visit

Come to your appointment armed with a detailed timeline that will help your doctor build a compelling case for medical necessity.

Create Your Treatment Timeline

Document every relevant treatment attempt:

  • Medication names, exact dosages, and duration of use
  • Specific reasons for discontinuation (ineffective, side effects, allergic reactions)
  • Dates of treatment periods
  • Any hospitalizations or emergency visits related to your condition

Track Functional Impact

Your doctor needs to understand how your condition affects daily life:

  • Work or school limitations
  • Physical restrictions or pain levels
  • Sleep disruption or cognitive effects
  • Impact on family relationships or caregiving responsibilities
Tip: Keep a symptom diary for 2-3 weeks before your appointment. Note severity (1-10 scale), triggers, and how symptoms interfere with activities.

Gather Insurance Information

Bring your current BCBS member ID card and know your plan type (HMO, PPO, or POS). If you've received any prior denials for Acthar Gel or related medications, bring those letters too.

Build Your Evidence Kit

Your doctor will need comprehensive clinical evidence to support the prior authorization request. Help them by organizing your medical history.

Essential Clinical Records

Laboratory and imaging results from the past 6-12 months that demonstrate:

  • Disease activity markers
  • Response to previous treatments
  • Any complications from prior therapies
  • Baseline organ function before starting Acthar Gel

Specialist consultation notes addressing:

  • Your specific diagnosis and ICD-10 codes
  • Treatment history and outcomes
  • Clinical rationale for Acthar Gel
  • Expected monitoring plan

Treatment History Summary

Create a one-page summary listing:

  • Corticosteroids tried: Include prednisone, methylprednisolone, or others with exact doses and durations
  • Immunosuppressive agents: Document any DMARDs, biologics, or other specialty medications
  • Reason for failure: Be specific about whether treatments were ineffective, caused intolerable side effects, or were contraindicated

Medical Necessity Letter Structure

Your doctor's letter of medical necessity is the cornerstone of your prior authorization request. Here's what BCBS Virginia expects to see:

Required Components

Patient Demographics and Clinical Context

  • Full name, DOB, member ID, and contact information
  • Primary diagnosis with ICD-10 code
  • Relevant medical history and comorbidities
  • Current functional status and disease severity

Comprehensive Treatment History

  • Detailed account of all corticosteroid trials with specific medications, doses, durations, and outcomes
  • Documentation of why each treatment was discontinued
  • Evidence of contraindications to standard therapies
  • Any adverse reactions or treatment failures

Clinical Rationale for Acthar Gel

  • Explanation of why Acthar Gel is medically necessary for this specific patient
  • Reference to FDA-approved indication
  • Expected treatment goals and monitoring plan
  • Citation of relevant clinical guidelines or peer-reviewed studies
From our advocates: "We've seen the strongest approvals when doctors include specific pharmacy records showing corticosteroid fills and detailed progress notes documenting treatment failures. A generic statement about 'failed steroids' isn't enough—BCBS wants to see the clinical story."

Supporting Evidence to Include

Your doctor should attach:

  • Recent chart notes and physical exam findings
  • Laboratory results showing disease activity
  • Imaging studies if relevant
  • Pharmacy records documenting prior medication trials
  • Any specialist consultation reports

Support Your Doctor During Peer-to-Peer Review

If BCBS requests a peer-to-peer review, your doctor will speak directly with their medical director. You can help by preparing key talking points.

Prepare a Concise Case Summary

Help your doctor prepare a 2-3 minute overview covering:

  • Your specific diagnosis and how it impacts function
  • Exact corticosteroids tried, doses, and why they failed
  • Any contraindications to standard treatments
  • Expected benefits from Acthar Gel based on your clinical presentation

Be Available for Questions

Let your doctor know your availability in case BCBS needs additional information during the review. Sometimes medical directors ask for clarification on treatment timelines or functional assessments.

Key Clinical Points for Your Doctor

For infantile spasms: Emphasize that you're under 2 years old, prescribed by a pediatric neurologist, and require intramuscular administration per FDA labeling.

For MS exacerbations: Document specific neurological deficits, failed high-dose corticosteroid trials, and any contraindications to standard treatments.

For other indications: Provide evidence of refractory disease despite appropriate first-line therapies and specialist management.

Document Everything After Your Visit

Proper documentation helps track your case and supports any needed appeals.

Save These Documents

  • Copy of the prior authorization request your doctor submitted
  • All supporting clinical documentation
  • BCBS confirmation numbers or reference numbers
  • Any correspondence from your doctor's office about the request status

Use Your Patient Portal

Most BCBS plans offer online portals where you can:

  • Check prior authorization status
  • View determination letters
  • Access your coverage details and formulary information
  • Message your care team about coverage issues

Track Important Dates

BCBS decision timeline: Standard prior authorization decisions are typically made within 72 hours for urgent requests and 14 days for standard requests.

Appeal deadlines: If denied, you have specific timeframes to file appeals—typically 60-180 days depending on your plan type.

Practice Respectful Persistence

Getting specialty drug coverage often requires follow-up. Here's how to advocate effectively while maintaining good relationships with your care team.

Appropriate Follow-Up Schedule

  • Week 1: Confirm your doctor submitted the PA request
  • Week 2: Check status if no decision received
  • Week 3: Contact BCBS member services directly if still pending
  • After denial: Discuss appeal options with your doctor within 48 hours

Professional Communication Scripts

When calling BCBS member services: "Hi, I'm calling to check the status of a prior authorization request for Acthar Gel. My member ID is [number] and the request was submitted on [date]. Can you tell me the current status and expected decision timeline?"

When messaging your doctor's office: "I wanted to follow up on my Acthar Gel prior authorization request from [date]. BCBS shows it's still pending—is there any additional information they need from your office?"

Appeals Process in Virginia

If BCBS denies your initial request, Virginia provides multiple levels of appeal with specific timelines and procedures.

Internal Appeals with BCBS

Standard Appeal Process:

  • File within 180 days of denial notice
  • Submit additional medical evidence
  • Decision within 30 days for standard appeals
  • Decision within 72 hours for expedited appeals

Required Documentation:

  • Copy of denial letter
  • Additional clinical evidence supporting medical necessity
  • Updated letter from your doctor addressing specific denial reasons

Virginia External Review Process

If BCBS upholds their denial after internal appeals, you can request external review through the Virginia State Corporation Commission Bureau of Insurance.

Timeline and Requirements:

  • Must file within 120 days of final BCBS denial
  • Submit Form 216-A (External Review Request)
  • Include signed medical records release
  • Provide copy of final determination letter

Contact Information:

  • Email: [email protected]
  • Fax: (804) 371-9915
  • Mail: SCC Bureau of Insurance – External Review, P.O. Box 1157, Richmond, VA 23218

Decision Timeline:

  • Standard review: 45 days
  • Expedited review: 72 hours (with physician certification of urgency)
Note: Virginia's external review process is free and provides independent medical review by specialists familiar with your condition.

Cost Assistance Options

Even with insurance coverage, Acthar Gel can have significant out-of-pocket costs. Several assistance programs may help.

Manufacturer Support Programs

Acthar Support Connect offers:

  • Copay assistance for eligible commercially insured patients
  • Prior authorization support services
  • Patient education resources
  • Injection training and supplies

Contact: Visit actharhcp.com or call the number provided on their website.

Foundation Assistance

Several patient assistance foundations provide grants for specialty medications:

  • The HealthWell Foundation
  • Patient Access Network Foundation
  • Good Days (formerly Chronic Disease Fund)
  • Patient Advocate Foundation

Eligibility varies but typically includes income requirements and diagnosis-specific criteria.

Virginia State Resources

Virginia's State Corporation Commission provides free consumer assistance for insurance disputes. The Managed Care Ombudsman can help navigate coverage issues and appeal processes.

Contact: 1-877-310-6560

Counterforce Health: Specialized Appeal Support

When facing complex prior authorization denials or appeals, Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters, plan policies, and clinical notes to identify the specific denial basis—whether it's prior authorization criteria, step therapy requirements, or "not medically necessary" determinations—then drafts point-by-point rebuttals aligned to your plan's own rules. For medications like Acthar Gel, Counterforce Health pulls the right clinical evidence including FDA labeling, peer-reviewed studies, and specialty guidelines, weaving them into appeals with required clinical facts like diagnosis codes, prior treatment failures, and dosing rationale.

FAQ

How long does BCBS prior authorization take for Acthar Gel in Virginia? Standard requests typically receive decisions within 14 days. Urgent requests are decided within 72 hours. Your doctor can request expedited review if treatment delays could harm your health.

What if Acthar Gel isn't on my BCBS formulary? You can request a formulary exception. Your doctor will need to provide clinical justification for why covered alternatives aren't appropriate for your specific condition.

Can I appeal if I've moved to Virginia from another state? Yes, but you'll need documentation of your treatment history from your previous state. Virginia's external review process applies to Virginia-issued plans or self-funded plans that opt in.

Does step therapy apply if I failed corticosteroids years ago? Recent treatment failures carry more weight, but your doctor can reference historical treatment failures if they're well-documented and relevant to your current condition.

What happens if the external review upholds the denial? The external review decision is final and binding. However, you retain rights to pursue legal action separately if you believe there were procedural violations.

How much does Acthar Gel cost without insurance? A single 5-mL vial typically costs tens of thousands of dollars. Even with insurance, copays can be substantial, making manufacturer assistance programs crucial.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by specific BCBS plan and individual circumstances. Always consult with your healthcare provider and insurance plan directly for personalized guidance. For additional help with insurance appeals in Virginia, contact the State Corporation Commission Bureau of Insurance at 1-877-310-6560.

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