By Counterforce Health Team in Cresemba (isavuconazole) —

Work With Your Doctor to Get Cresemba (Isavuconazole) Approved by Blue Cross Blue Shield in New Jersey: PA Forms, Appeals, and Medical Necessity Letters

Quick Answer: Getting Cresemba Approved by Blue Cross Blue Shield in New Jersey

Eligibility: Cresemba requires prior authorization for invasive aspergillosis or mucormycosis with confirmed diagnosis and often ID specialist involvement. Fastest path: Have your infectious disease specialist submit a comprehensive medical necessity letter documenting failed voriconazole therapy or contraindications, along with culture/pathology results. Start today: Contact your BCBS plan to request current PA forms and criteria, then schedule an appointment with your ID specialist to begin documentation. If denied, New Jersey's IHCAP external review through Maximus offers binding decisions within 45 days.

Table of Contents

  1. Set Your Goal: What BCBS Approval Requires
  2. Visit Prep: Gathering Your Medical History
  3. Evidence Kit: Clinical Documentation You'll Need
  4. Medical Necessity Letter Structure
  5. Peer-to-Peer Support Strategy
  6. After-Visit Documentation
  7. Appeals Process in New Jersey
  8. Common Denial Reasons & Solutions
  9. Cost Assistance Programs
  10. FAQ

Set Your Goal: What BCBS Approval Requires

Cresemba (isavuconazole) is a specialty antifungal medication that typically requires prior authorization from Blue Cross Blue Shield plans in New Jersey. Your goal is to work with your healthcare team to demonstrate medical necessity through comprehensive documentation.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization BCBS must approve before dispensing Horizon BCBS PA Search Tool
Confirmed Diagnosis ICD-10 codes B44.0-B44.9 (aspergillosis) or B46.0-B46.9 (mucormycosis) Medical records, pathology reports
ID Specialist Involvement Infectious disease consultation often required Referral from primary care or hospitalist
Failed Prior Therapy Documentation of voriconazole failure/intolerance Treatment records, adverse event notes
Diagnostic Evidence Culture, pathology, or imaging confirmation Lab reports, biopsy results

Partnership Strategy: Your infectious disease specialist will be your primary advocate. They understand the clinical criteria and can navigate the medical necessity requirements that BCBS uses to evaluate Cresemba requests.

Visit Prep: Gathering Your Medical History

Before meeting with your infectious disease specialist, compile a comprehensive timeline of your condition and treatments.

Symptom Timeline Documentation

Create a chronological record including:

  • Initial symptoms and when they started
  • Hospitalizations with dates and discharge summaries
  • Diagnostic procedures performed (bronchoscopy, biopsy, imaging)
  • Treatment responses to previous antifungal medications

Prior Treatment Documentation

Gather records of all antifungal treatments you've received:

Voriconazole History (critical for Cresemba approval):

  • Exact dates of therapy
  • Dosing and duration
  • Reason for discontinuation (failure, side effects, contraindications)
  • Specific adverse events experienced

Other Antifungals Tried:

  • Amphotericin B formulations
  • Posaconazole
  • Fluconazole or itraconazole
  • Outcomes and tolerability

Functional Impact Notes

Document how your condition affects daily activities:

  • Work or school limitations
  • Physical symptoms (fatigue, breathing difficulties)
  • Quality of life impacts
  • Caregiver assistance needed
Tip: Use your patient portal to request copies of all relevant records before your appointment. This saves time and ensures nothing is missed.

Evidence Kit: Clinical Documentation You'll Need

Your infectious disease specialist will need specific clinical evidence to support the Cresemba request.

Diagnostic Confirmation Requirements

For Invasive Aspergillosis:

  • Positive culture from bronchoalveolar lavage (BAL) or respiratory specimens
  • Galactomannan antigen testing (serum or BAL fluid)
  • CT imaging showing characteristic findings (halo sign, cavitation)
  • Histopathological evidence if tissue obtained

For Mucormycosis:

  • Tissue biopsy with histological confirmation
  • Culture identification of Mucorales organisms
  • Imaging studies showing tissue invasion
  • Surgical consultation notes if applicable

Laboratory Evidence Package

Compile these test results:

  • Complete blood count with differential
  • Comprehensive metabolic panel
  • Liver function tests (baseline for antifungal monitoring)
  • Inflammatory markers (CRP, ESR)
  • Immunosuppression status documentation

Published Guidelines Support

Your specialist may reference these authoritative sources:

Medical Necessity Letter Structure

The medical necessity letter is the cornerstone of your prior authorization request. Here's what your infectious disease specialist should include:

Essential Components Checklist

Patient Information Section:

  • Full name, date of birth, insurance ID
  • Primary and secondary diagnoses with ICD-10 codes
  • Relevant medical history and risk factors

Clinical Presentation:

  • Detailed description of current condition
  • Diagnostic workup performed and results
  • Severity assessment and prognosis

Treatment Rationale:

  • Why Cresemba is specifically indicated
  • Clinical guidelines supporting its use
  • Expected treatment duration and monitoring plan

Prior Therapy Documentation:

  • Complete list of previous antifungal treatments
  • Specific reasons for treatment failures
  • Adverse events or contraindications to alternatives

Supporting Literature:

  • References to peer-reviewed studies
  • Professional society guidelines
  • FDA labeling information
Clinician Corner: When documenting voriconazole intolerance, be specific about adverse events. Common reasons include visual disturbances, hepatotoxicity, skin reactions, or drug interactions. Include dates, severity, and impact on patient care.

Peer-to-Peer Support Strategy

If your initial prior authorization is denied, BCBS may offer a peer-to-peer review where your specialist speaks directly with a medical director.

Preparing for Peer-to-Peer Review

Offer Availability Windows:

  • Provide multiple time slots when your specialist is available
  • Request the medical director's specialty background
  • Prepare a concise case summary (2-3 minutes)

Key Talking Points:

  • Patient's specific clinical scenario
  • Why standard alternatives aren't appropriate
  • Literature supporting Cresemba use
  • Risks of treatment delay

Documentation to Have Ready:

  • Recent culture results
  • Imaging studies
  • Treatment timeline
  • Adverse event records

Sample Peer-to-Peer Script

"This is a [age]-year-old patient with [underlying condition] who developed proven invasive aspergillosis confirmed by [specific test]. We initiated voriconazole but had to discontinue due to [specific adverse event]. Given the severity of infection and contraindication to first-line therapy, Cresemba represents the most appropriate treatment option per IDSA guidelines."

After-Visit Documentation

After your appointment, ensure proper documentation and follow-up.

What to Save

  • Complete visit notes from your specialist
  • Updated treatment plan
  • Prior authorization submission confirmation
  • Any additional test orders

Patient Portal Communication

Use your healthcare system's patient portal to:

  • Request copies of all documentation
  • Ask clarifying questions about the treatment plan
  • Provide updates on insurance communications
  • Schedule follow-up appointments

Insurance Communication Log

Keep a detailed record of all interactions:

  • Date and time of calls
  • Representative names and ID numbers
  • Case or reference numbers
  • Outcomes and next steps

Appeals Process in New Jersey

If your Cresemba prior authorization is denied, New Jersey offers a comprehensive appeals process.

Internal Appeals Timeline

Level Deadline to File Decision Timeframe
Level 1 Internal Appeal 180 days from denial 15 days (pre-service) / 30 days (post-service)
Level 2 Internal Appeal 60 days from Level 1 decision 15 days (pre-service) / 30 days (post-service)
Expedited Appeal Concurrent with above 72 hours

New Jersey IHCAP External Review

After completing internal appeals, you can file an external appeal with New Jersey's Independent Health Care Appeals Program (IHCAP), now administered by Maximus Federal Services.

Key Details:

  • Filing deadline: 4 months after final internal appeal decision
  • Decision timeline: 45 days for standard appeals, 48 hours for expedited
  • Cost: Free to patients
  • Binding decision: Insurers must comply with IHCAP determinations

How to File: Submit your external appeal to Maximus IHCAP with:

  • Completed external appeal application
  • Copy of internal appeal decision letters
  • Brief description of medical condition
  • Authorization for medical record release
Note: New Jersey's IHCAP has a strong track record of overturning inappropriate denials. Approximately half of external appeals nationwide favor consumers, and New Jersey's process is particularly patient-friendly.

Common Denial Reasons & Solutions

Understanding why Cresemba requests are denied helps you prepare a stronger initial submission.

Denial Reason: "Step Therapy Not Completed"

Solution: Document voriconazole trial with specific:

  • Start and stop dates
  • Dosing regimen used
  • Reason for discontinuation
  • Clinical monitoring results

Denial Reason: "Diagnosis Not Confirmed"

Solution: Provide definitive diagnostic evidence:

  • Positive cultures with species identification
  • Histopathological confirmation
  • Radiographic findings
  • Laboratory markers (galactomannan, beta-D-glucan)

Denial Reason: "Prescriber Not Qualified"

Solution: Ensure infectious disease specialist involvement:

  • ID consultation note
  • Board certification documentation
  • Hospital privileges verification
  • Specialist co-signature on requests

Denial Reason: "Not Medically Necessary"

Solution: Strengthen clinical rationale:

  • Reference published guidelines
  • Document treatment urgency
  • Explain risks of alternative therapies
  • Include specialist attestation

Cost Assistance Programs

Even with insurance approval, Cresemba can be expensive. Several programs may help reduce costs.

Manufacturer Support

CRESEMBA Support Solutions offers:

  • Prior authorization assistance
  • Appeals support
  • Copay assistance programs
  • Patient access services

Foundation Assistance

Consider these patient assistance foundations:

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

State Programs

New Jersey residents may qualify for:

  • Pharmaceutical Assistance to the Aged and Disabled (PAAD)
  • Senior Gold Prescription Discount Program
  • NJ FamilyCare prescription benefits
From our advocates: We've seen patients successfully reduce their Cresemba costs from over $1,500 per month to under $50 by combining insurance approval with manufacturer copay assistance and foundation grants. The key is applying to multiple programs simultaneously, as eligibility criteria vary and funding availability changes throughout the year.

FAQ

How long does BCBS prior authorization take in New Jersey? Standard prior authorization decisions are typically made within 5-7 business days for routine requests. Expedited reviews for urgent cases can be completed within 72 hours.

What if Cresemba is not on my BCBS formulary? You can request a formulary exception by demonstrating medical necessity. Your specialist will need to provide evidence that formulary alternatives are inappropriate or ineffective for your condition.

Can I start Cresemba while waiting for approval? In emergency situations, hospitals may provide initial doses while pursuing urgent prior authorization. Discuss this option with your infectious disease specialist if treatment delay poses serious risks.

Does step therapy apply if I failed voriconazole outside New Jersey? Yes, prior treatment failures from other states count toward step therapy requirements. Ensure your New Jersey specialist has complete records of previous treatments and outcomes.

How much does Cresemba cost without insurance? The wholesale acquisition cost is approximately $394 per IV vial or $1,620 for a 14-day supply of oral capsules. Patient costs vary significantly based on pharmacy and insurance coverage.

What happens if IHCAP overturns my denial? BCBS must comply with IHCAP decisions and provide coverage as determined by the external review. The insurer typically has 10 business days to implement the decision.

Can my doctor file the external appeal for me? Yes, healthcare providers can file external appeals on behalf of patients with proper authorization. Many specialists are familiar with the IHCAP process and can assist with submission.

Are there alternatives if all appeals fail? If insurance appeals are unsuccessful, explore manufacturer patient assistance programs, clinical trials, or compassionate use protocols. Your infectious disease specialist can help identify additional options.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that address specific payer requirements. We understand the complexities of prior authorization and can help streamline the approval process for specialty medications like Cresemba.

For comprehensive support with your Cresemba prior authorization or appeal, consider leveraging Counterforce Health's expertise in navigating insurance requirements and crafting compelling medical necessity arguments.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies, prior authorization requirements, and appeal processes may change. Always consult with your healthcare provider and insurance plan for the most current information regarding coverage and treatment options. For specific questions about New Jersey insurance regulations, contact the NJ Department of Banking and Insurance.

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