Counterforce Health Team

Work With Your Doctor to Get Translarna (Ataluren) Approved by Humana in Ohio: Complete Prior Authorization Guide

Answer Box: Getting Translarna (Ataluren) Covered by Humana in Ohio Translarna requires prior authorization from Humana across all plan types and is typically non-formulary, requiring a formulary exception with clinical justification. Your doctor must document: (1) genetic testing confirming nonsense mutation DMD, (2) current ambulatory status, and (3) corticosteroid trial

How to Get Abecma (idecabtagene vicleucel) Covered by Humana in Pennsylvania: Complete Guide to Prior Authorization and Appeals

Quick Answer: Abecma (idecabtagene vicleucel) requires prior authorization from Humana Medicare Advantage plans for adults with relapsed/refractory multiple myeloma after ≥4 prior therapy lines. Submit through Humana's National Transplant Network at 866-421-5663 with complete treatment history documentation. If denied, Pennsylvania's new Independent External Review program

Getting Firdapse (Amifampridine) Approved by Humana in California: Complete Prior Authorization Guide with Appeal Strategies

Quick Answer: Getting Firdapse Approved by Humana in California Firdapse (amifampridine) requires prior authorization from Humana Medicare Advantage/Part D plans in California as a Tier 5 specialty drug. Your neuromuscular specialist must submit the PA request with confirmed LEMS diagnosis (anti-P/Q VGCC antibodies + EMG showing >60% CMAP

How to Get Vimizim (Elosulfase Alfa) Covered by UnitedHealthcare in North Carolina: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Vimizim Covered by UnitedHealthcare in North Carolina Prior authorization is required for Vimizim (elosulfase alfa) through UnitedHealthcare's OptumRx formulary. Submit PA via the UnitedHealthcare Provider Portal with complete MPS IVA diagnosis documentation, GALNS enzyme deficiency confirmation, and medical necessity justification. Standard decisions take 72 hours;

How to Get Opfolda (miglustat) Covered by UnitedHealthcare in Michigan: Complete PA Guide, Appeals Process & Forms

Answer Box: Getting Opfolda Covered by UnitedHealthcare in Michigan UnitedHealthcare requires prior authorization for Opfolda (miglustat) through OptumRx, and it must be prescribed with Pombiliti for late-onset Pompe disease in adults ≥40 kg who aren't improving on current enzyme replacement therapy. Submit both PAs simultaneously via the UnitedHealthcare

How to Get Pemazyre (Pemigatinib) Covered by Cigna in New Jersey: Prior Authorization Forms, Appeal Scripts, and External Review Guide

Answer Box: Quick Path to Pemazyre Coverage To get Pemazyre (pemigatinib) covered by Cigna in New Jersey: 1) Have your doctor submit a prior authorization with FGFR2 fusion testing results, baseline eye exam, and documented prior therapy failures. 2) If denied, file an internal appeal within 180 days using Cigna&

UnitedHealthcare's Coverage Criteria for Procysbi in Texas: What Counts as "Medically Necessary"?

Answer Box: Getting Procysbi Covered by UnitedHealthcare in Texas UnitedHealthcare requires prior authorization (PA) for Procysbi with step therapy mandating trial of immediate-release cysteamine first. To get approval: (1) Submit PA through UHC provider portal with nephropathic cystinosis diagnosis and WBC cystine levels, (2) Document Cystagon failure/intolerance with specific

How to Get Stelara (Ustekinumab) Covered by Cigna in Florida: Complete PA Guide with Appeal Forms

Answer Box: Getting Stelara Covered by Cigna in Florida Cigna requires prior authorization (PA) for Stelara (ustekinumab) in Florida, with step therapy and specialist requirements. Your fastest path: Have your dermatologist or gastroenterologist complete Cigna's PA form showing failed trials of preferred biologics. Submit via CoverMyMeds or fax

How to Get Elaprase (Idursulfase) Covered by Aetna (CVS Health) in Illinois: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Elaprase (Idursulfase) Covered by Aetna (CVS Health) in Illinois Aetna (CVS Health) requires prior authorization for Elaprase (idursulfase) with confirmed Hunter syndrome diagnosis via enzyme assay or genetic testing. Submit Aetna's Elaprase Precertification Form (GR-69518) through your metabolic specialist with weight-based dosing calculations. Illinois provides

How to Get Lutathera (Lutetium Lu-177 Dotatate) Covered by Cigna in Ohio: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Lutathera Covered by Cigna in Ohio Yes, Cigna covers Lutathera (lutetium Lu-177 dotatate) for somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors, but prior authorization is required. Your fastest path to approval: 1) Have your oncologist submit a PA request with SSTR-positive imaging (Ga-68 DOTATATE PET/CT), pathology confirming well-differentiated