Counterforce Health Team

Renewing Mycapssa (Octreotide Oral) Approval with UnitedHealthcare in North Carolina: Complete 2025 Guide

Answer Box: Mycapssa Renewal Essentials UnitedHealthcare requires annual reauthorization for Mycapssa (oral octreotide) in North Carolina, approving 12-month renewals based on documented clinical response—typically normalized IGF-1 levels and symptom improvement. Submit renewal requests 30-60 days before expiration via the OptumRx Provider Portal or fax (866-889-8054) with recent labs, treatment

How to Get Signifor LAR (Pasireotide) Covered by Aetna CVS Health in Ohio: Complete Prior Authorization Guide with Appeals Timeline

Answer Box: Getting Signifor LAR Covered by Aetna CVS Health in Ohio Signifor LAR (pasireotide) requires prior authorization from Aetna CVS Health and is non-preferred on their formulary. To get coverage in Ohio: (1) Submit complete PA documentation showing elevated cortisol/IGF-1 levels, surgical failure/contraindication, and specialist prescriber, (2)

Coding That Helps Get Ilaris (Canakinumab) Approved by Cigna in Georgia: ICD-10, HCPCS J0638, and NDC Requirements

Answer Box: Getting Ilaris Covered by Cigna in Georgia Ilaris (canakinumab) requires prior authorization from Cigna using HCPCS code J0638 (1 mg = 1 billing unit) with specific ICD-10 codes for Still's disease (M06.1), periodic fever syndromes (M04.1), or gout flares. Submit PA with CRP ≥10 mg/

How to Get Humate-P Covered by UnitedHealthcare in Washington: Prior Authorization, Appeals & State Protections

Answer Box: Getting Humate-P Covered by UnitedHealthcare in Washington UnitedHealthcare requires prior authorization (PA) for Humate-P (antihemophilic factor/vWF complex) with step therapy mandating desmopressin (DDAVP) trial first unless contraindicated. Submit PA requests via the UHC Provider Portal or call OptumRx at 1-800-711-4555. Standard processing takes 7 days; expedited requests

Denied for Kalydeco (ivacaftor) by Cigna in Illinois? How to Appeal (Templates & Timelines)

Quick Answer: Cigna requires prior authorization for Kalydeco (ivacaftor) with CFTR genetic testing proof and CF specialist documentation. Submit via CoverMyMeds or fax (855) 840-1678; standard review takes 5 business days. If denied, file internal appeal within 180 days, then Illinois external review within 4 months. Contact Illinois DOI at

How to Get Enbrel (Etanercept) Covered by Blue Cross Blue Shield in Washington: Complete PA Guide & Appeal Process

Answer Box: Getting Enbrel Covered by Blue Cross Blue Shield in Washington Blue Cross Blue Shield of Washington (Premera Blue Cross) requires prior authorization for Enbrel (etanercept) and typically mandates step therapy with biosimilar alternatives first. Here's your fastest path to approval: 1. Complete PA form: Have your

How to Get Jynarque (Tolvaptan) Covered by Blue Cross Blue Shield in California: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Jynarque Covered in California Blue Shield of California requires prior authorization for Jynarque (tolvaptan) for ADPKD patients 18+ prescribed by nephrologists. Submit via AuthAccel portal or fax (800) 633-4581 with baseline eGFR, imaging showing rapid progression, and REMS enrollment. Standard review takes 14 business days. If denied,

Get Darzalex Covered by Cigna in Illinois: Complete Prior Authorization and Appeal Guide

Answer Box: Getting Darzalex Covered by Cigna in Illinois Cigna requires prior authorization for both Darzalex IV and Darzalex Faspro (subcutaneous) under most commercial plans in Illinois. Submit the official PA form via CoverMyMeds or fax to (855) 840-1678. Standard approval takes 5 business days; expedited reviews process in 72

Myths vs. Facts: Getting Adynovate (bdanocog alfa pegol) Covered by Humana in Georgia

Answer Box: Key Facts for Georgia Patients Myth: If your doctor prescribes Adynovate, Humana must cover it. Fact: Humana requires prior authorization for all Factor VIII products, including Adynovate, with specific medical necessity criteria. Success depends on proper documentation, not just a prescription. In Georgia, you have 65 days to

How to Get Photrexa (Riboflavin) Covered by Aetna CVS Health in Florida: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Photrexa Covered by Aetna CVS Health in Florida Photrexa (riboflavin ophthalmic solution) requires prior authorization from Aetna CVS Health in Florida. Submit PA request through Availity provider portal with: keratoconus progression documentation (Kmax values), failed conservative treatments, FDA-approved iLink system confirmation. Standard decision: 30-45 days. If denied,