Counterforce Health Team

Getting Defitelio (Defibrotide) Covered by Blue Cross Blue Shield in New York: PA Requirements, Appeals, and Cost Assistance

Answer Box: Getting Defitelio Covered by Blue Cross Blue Shield in New York Defitelio (defibrotide) requires prior authorization from Blue Cross Blue Shield plans in New York for hepatic veno-occlusive disease (VOD) with organ dysfunction post-HSCT. Your fastest path: (1) Have your transplant team submit PA with VOD diagnosis documentation

How to Get Nucala (Mepolizumab) Covered by UnitedHealthcare in Washington: State Appeals Guide with Forms and Timelines

Answer Box: Getting Nucala Covered in Washington Washington residents have strong protections when UnitedHealthcare denies Nucala (mepolizumab) for severe eosinophilic asthma. State law requires step therapy exceptions within 72 hours if prior biologics failed or are contraindicated. After internal appeals, you can request binding external review through an Independent Review

How to Get Signifor LAR (Pasireotide) Covered by Aetna CVS Health in Georgia: Complete Appeals Guide with Forms and Timelines

Answer Box: Getting Signifor LAR Covered by Aetna CVS Health in Georgia Signifor LAR (pasireotide) requires prior authorization from Aetna CVS Health and is listed as non-preferred. To get coverage in Georgia: (1) Submit PA request through CVS Specialty with complete biochemical evidence (UFC/IGF-1 levels) and documented failure of

How to Get Carbaglu (Carglumic Acid) Covered by UnitedHealthcare in North Carolina: Complete Appeal Guide with Forms and Timelines

Answer Box: Getting Carbaglu Covered by UnitedHealthcare in North Carolina UnitedHealthcare requires prior authorization for Carbaglu (carglumic acid) with 12-month approval periods. Key requirements include documented NAGS deficiency diagnosis, elevated ammonia levels, and metabolic specialist oversight. If denied, you have 180 days to appeal internally, then 120 days to request

How to Get Tegsedi (Inotersen) Covered by Humana in Washington: Prior Authorization, Appeals, and Cost Assistance

Answer Box: Getting Tegsedi (Inotersen) Covered by Humana in Washington Note: Tegsedi was discontinued in September 2024 - verify current availability before proceeding. Getting Tegsedi covered by Humana requires prior authorization with specific documentation: genetic confirmation of hATTR polyneuropathy, specialist prescription, REMS enrollment, and baseline labs. In Washington, if denied,

How to Get Evrysdi (Risdiplam) Covered by Humana in North Carolina: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Evrysdi Covered by Humana in North Carolina Humana requires prior authorization for Evrysdi (risdiplam) with genetic confirmation of SMA, motor function assessments, and specialist documentation. Submit via Humana's provider portal with complete clinical records for 72-hour standard review (24-hour expedited if urgent). If denied, you

Get Humira (Adalimumab) Approved by Blue Cross Blue Shield North Carolina: Complete Forms, Appeals & Contact Guide

Answer Box: Getting Humira Approved by BCBS North Carolina Blue Cross Blue Shield of North Carolina requires prior authorization for Humira (adalimumab) with step therapy through preferred biosimilars first. Submit PA via the Availity Provider Portal or call 800-672-7897. Include clinical documentation of biosimilar failures, diagnosis codes, and medical necessity.

How to Get Enhertu (fam-trastuzumab deruxtecan-nxki) Covered by Blue Cross Blue Shield in New York: Complete Prior Authorization and Appeal Guide

Quick Answer: Getting Enhertu Covered by BCBS in New York Enhertu (fam-trastuzumab deruxtecan-nxki) requires prior authorization from Blue Cross Blue Shield plans in New York for HER2-positive breast cancer, NSCLC, and gastric cancer. Key requirements include documented HER2 status (IHC 3+ or ISH amplified), prior trastuzumab-based therapy failure, and NCCN

How to Get Alprolix (Factor IX) Covered by Aetna CVS Health in North Carolina: Forms, Appeals, and Success Timeline

Answer Box: Getting Alprolix Covered by Aetna CVS Health in North Carolina Alprolix (eftrenonacog alfa) is excluded from most Aetna formularies, requiring a medical exception request rather than standard prior authorization. Your hematologist must submit comprehensive documentation through Aetna's provider portal or fax to 1-888-267-3277. If denied, North

How to Get Zolgensma (onasemnogene abeparvovec-xioi) Covered by Cigna in Illinois: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Zolgensma Covered by Cigna in Illinois Zolgensma (onasemnogene abeparvovec-xioi) requires prior authorization from Cigna for pediatric patients under 2 years with spinal muscular atrophy (SMA). Key requirements: genetic confirmation of ≤3 SMN2 copies, anti-AAV9 antibodies ≤1:50, baseline labs within 30 days, and prescription by an SMA