BCBS AFFILIATEPA, WV, DEPBM: Express Scripts

Highmark BCBS (Western PA, WV, DE) Prior Authorization Guide

Submit prior authorization requests and appeal denials with Highmark BCBS. Phone numbers, fax numbers, appeal deadlines, step therapy override rights, and clinical documentation tips for PA, WV, DE providers.

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Prior Authorization Contacts

PA PHONE

1-800-547-3627

PA FAX

1-800-313-2023

TURNAROUND

30 days standard, 72h expedited

TIMELY FILING

180 days

APPEALS MAILING ADDRESS

Highmark Appeals, PO Box 535047, Pittsburgh, PA 15253

Common Denial Reasons

⚠ Highmark Medical Policy criteria not met
⚠ Step therapy
⚠ Site of care (home infusion preferred over hospital)
⚠ Non-formulary

Step Therapy Requirements & Override Rights

Highmark covers PA (western), WV, and DE. Pennsylvania Act 25 of 2020 provides step therapy override rights with 72-hour response requirement. Highmark typically requires TNF inhibitor trial before IL-17/IL-23 biologics.

Tips for Highmark BCBS Submissions

1. Highmark Medical Policy applies across PA/WV/DE
2. PA Act 25 provides step therapy override rights
3. Submit via Availity
4. Express Scripts is the PBM

External Review Authority

If Highmark BCBS denies your final internal appeal, you have the right to request an external review through: PA Insurance Department / WV Offices of the Insurance Commissioner / DE Insurance Commissioner.

External review decisions are binding on the insurer.