Why Anthem BCBS Denies Biologic Therapy (Autoimmune)
Step therapy not completed (conventional DMARDs first)
Prior biologic trial not documented
Biosimilar required before brand-name biologic
Know Anthem / Blue Cross Blue Shield's Criteria
Anthem uses their own Clinical UM Guidelines and AIM Specialty Health for imaging. Medical policy numbers are publicly searchable.
Key policies to know:
- AIM Specialty Health manages imaging prior auth
- Clinical UM Guidelines searchable at anthem.com/provider
- Known for strict imaging prior auth requirements
- Uses evidence-based medicine approach with published policies
Anthem BCBS's Specific Approach to Biologic Therapy (Autoimmune)
Applicable Policy
Anthem Pharmacy Policy (varies by drug and state plan)
How Anthem BCBS Typically Denies This
Anthem varies significantly by state plan for biologic coverage. Some state BCBS plans have different formularies and step therapy requirements. Anthem generally requires conventional DMARD failure but may not require two agents.
Your Strategy for This Payer
Check the specific state plan's formulary and prior auth criteria -- Anthem BCBS is really 36 different companies. The criteria in California BCBS may differ from Anthem Virginia. Lead with disease activity scores.
Key Phrase to Use on the Call
"With a DAS28 of [X] / CDAI of [X] despite [conventional DMARD] therapy, this patient has active disease meeting criteria for biologic initiation under the [specific state plan] formulary."
Building Your Medical Necessity Argument
Document failure, intolerance, or contraindication to step therapy agents
Note disease activity scores (DAS28, CDAI, PASI)
If biosimilar switch requested, document clinical reason for brand
Reference comorbidities that limit alternative treatments
P2P Call Tips for Anthem BCBS
Reference specific Anthem Clinical UM Guideline by policy number
For imaging, address AIM criteria specifically
Anthem medical directors appreciate evidence-based arguments
Cite specific clinical criteria being met from their own policy
Guidelines to Reference
- ACR Guidelines for Rheumatoid Arthritis Treatment
- AGA Guidelines for Biologic Therapy in IBD
- AAD Guidelines for Biologic Therapy in Psoriasis
Relevant CPT Codes
Specialty: Rheumatology / Gastroenterology / Dermatology
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