Counterforce Health Team

Myths vs. Facts: Getting Vyondys 53 (golodirsen) Covered by UnitedHealthcare in New York

Answer Box: Getting Vyondys 53 Covered by UnitedHealthcare in New York Vyondys 53 (golodirsen) requires prior authorization from UnitedHealthcare and is billed as a medical benefit under J1429. Key requirements: confirmed exon 53-amenable DMD mutation via genetic testing, ambulatory status (6MWT ≥300m), and neuromuscular specialist involvement. If denied, New York

How to Get Emflaza (Deflazacort) Covered by Humana in California: Complete Coding, Prior Authorization & Appeals Guide

Answer Box: Getting Emflaza Covered by Humana in California Emflaza (deflazacort) requires prior authorization from Humana and uses ICD-10 code G71.01 for Duchenne muscular dystrophy. Most approvals require documented failure of prednisone due to weight gain or behavioral issues. If denied, California residents can appeal through Humana's

How to Get Zolgensma Covered by UnitedHealthcare in Florida: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Zolgensma Approved by UnitedHealthcare in Florida UnitedHealthcare requires prior authorization for Zolgensma with strict criteria: confirmed SMN1 mutations, age under 2 years, anti-AAV9 antibody titers ≤1:50, and administration at certified infusion centers. Start by submitting genetic testing results and AAV9 titers through the UHC provider portal.

How to Get Trikafta (elexacaftor/tezacaftor/ivacaftor) Covered by Cigna in Georgia: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Trikafta Covered by Cigna in Georgia Cigna requires prior authorization for Trikafta (elexacaftor/tezacaftor/ivacaftor) with complete CFTR genotype testing, CF specialist prescription, and clinical documentation. Standard approval takes 5 business days; expedited reviews available in 24-72 hours for urgent cases. If denied, Georgia law provides strong

How to Get Abecma (idecabtagene vicleucel) Covered by Aetna (CVS Health) in Pennsylvania: Appeals Guide 2025

Answer Box: Getting Abecma Covered in Pennsylvania Abecma (idecabtagene vicleucel) requires prior authorization from Aetna (CVS Health) in Pennsylvania. Submit through your oncologist at a certified CAR-T center with documentation of ≥4 prior therapy failures, adequate organ function, and NCCN guideline support. If denied, Pennsylvania's new external review

Work With Your Doctor to Get Lutathera (Lutetium Lu-177 Dotatate) Approved by Humana in Virginia: Complete Provider Collaboration Guide

Answer Box: Getting Lutathera Covered by Humana in Virginia Lutathera (lutetium Lu-177 dotatate) requires prior authorization from Humana Medicare Advantage plans in Virginia, with step therapy requirements for non-preferred status. Your oncologist must document somatostatin receptor-positive imaging (Ga-68 DOTATATE PET), failed prior treatments, and medical necessity. If denied, Virginia'

Renewing Rinvoq (Upadacitinib) Approval with UnitedHealthcare in New York: Timeline, Documentation & Appeal Options

Answer Box: UnitedHealthcare approves Rinvoq renewals for 12 months with documented clinical response and safety labs. Start renewal 45-60 days before expiration by scheduling response assessment, gathering current labs (CBC, liver function, lipids), and submitting via OptumRx portal. If denied, file internal appeal within 180 days, then external review through

How to Get Alecensa (Alectinib) Covered by UnitedHealthcare in Michigan: Complete Prior Authorization Guide

Answer Box: Getting Alecensa Covered by UnitedHealthcare in Michigan UnitedHealthcare requires prior authorization for Alecensa (alectinib) in Michigan for ALK-positive NSCLC, with no step therapy requirements. Submit PA through the UnitedHealthcare Provider Portal with ALK test results, oncologist prescription, and diagnosis documentation. If denied, file internal appeal within 30 days,

How to Get Pomalyst (pomalidomide) Covered by Humana in Georgia: Complete Prior Authorization Guide and Appeals Process

Answer Box: Quick Path to Pomalyst Coverage Getting Pomalyst (pomalidomide) covered by Humana in Georgia requires prior authorization with step therapy documentation. You must show failure of lenalidomide (Revlimid) plus a proteasome inhibitor, enroll in the PS-Pomalidomide REMS program, and have your oncologist submit medical necessity documentation. First step today:

How to Get Cabometyx (cabozantinib) Covered by Humana in Illinois: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Cabometyx Covered by Humana in Illinois Cabometyx (cabozantinib) requires prior authorization from Humana Medicare plans in Illinois as a Tier 5 specialty drug. Your oncologist must submit a PA request documenting your cancer diagnosis (kidney, liver, or thyroid), prior treatments, imaging results, and NCCN guideline justification. Standard