Counterforce Health Team

Cigna's Coverage Criteria for Trikafta in Florida: What Counts as "Medically Necessary"?

Answer Box: Getting Trikafta Covered by Cigna in Florida Cigna requires prior authorization (PA) for Trikafta in Florida with documented cystic fibrosis diagnosis (ICD-10 E84.0), confirmed CFTR genotype (F508del or responsive mutations), and prescription from a CF specialist. Standard PA review takes 5 business days; expedited review available for

How to Get Tracleer (Bosentan) Covered by Humana in California: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Tracleer (Bosentan) Covered by Humana in California Tracleer (bosentan) requires prior authorization from Humana plus mandatory enrollment in the Bosentan REMS program. Your fastest path to approval: (1) Confirm WHO Group 1 PAH diagnosis via right heart catheterization, (2) Complete REMS enrollment at BosentanREMSProgram.com with baseline

Getting Emflaza (Deflazacort) Approved by UnitedHealthcare in Illinois: Complete Guide with Forms and Appeal Scripts

Answer Box: Getting Emflaza Approved by UnitedHealthcare in Illinois UnitedHealthcare requires prior authorization for Emflaza (deflazacort) with step therapy requiring prednisone failure first. To get approval: 1) Have your neurologist document DMD diagnosis and prednisone intolerance/failure, 2) Submit PA via OptumRx portal or call 1-800-711-4555, 3) If denied, appeal

How to Get Brineura (Cerliponase Alfa) Covered by Cigna in Illinois: Appeals Guide with Forms and Timelines

Answer Box: Getting Brineura (Cerliponase Alfa) Covered by Cigna in Illinois Brineura requires prior authorization from Cigna for confirmed CLN2 disease patients ≥3 years old. The fastest path: Submit PA through Express Scripts/Accredo with TPP1 enzyme deficiency results, genetic testing, and a pediatric neurologist's letter documenting motor

Work With Your Doctor to Get Tecentriq (Atezolizumab) Approved by UnitedHealthcare in California: Complete Provider Collaboration Guide

Answer Box: Getting Tecentriq Approved by UnitedHealthcare in California UnitedHealthcare requires prior authorization (PA) for Tecentriq (atezolizumab) through OptumRx, with specific clinical documentation including PD-L1 testing, biomarkers, and prior treatment history. The fastest path: 1) Submit PA via UnitedHealthcare Provider Portal with complete clinical evidence, 2) Request peer-to-peer review if

How to Get Vimizim (elosulfase alfa) Covered by Blue Cross Blue Shield in Washington: Appeals Guide & Templates

Quick Answer: Getting Vimizim Covered by Blue Cross Blue Shield in Washington Blue Cross Blue Shield Washington (Premera) requires prior authorization for Vimizim (elosulfase alfa) with specific diagnostic and functional testing requirements. To get coverage: 1) Submit PA request with confirmed MPS IVA diagnosis via GALNS enzyme testing or genetic

Myths vs. Facts: Getting Vyndaqel / Vyndamax (tafamidis) Covered by Blue Cross Blue Shield in Washington

Answer Box: The Reality of Vyndaqel Coverage Myth: If your cardiologist prescribes Vyndaqel/Vyndamax (tafamidis), Blue Cross Blue Shield automatically covers it. Fact: BCBS requires prior authorization with confirmed ATTR-CM diagnosis (PYP scan Grade 2-3, AL amyloidosis ruled out), NYHA Class I-III heart failure, and cardiology oversight. Success depends on

Renewing Therakos CELLEX Photopheresis Coverage with Aetna (CVS Health) in Illinois: Timeline, Documentation & Appeal Options

Quick Answer: Renewing Your Therakos CELLEX Coverage Aetna (CVS Health) requires prior authorization renewal for Therakos CELLEX photopheresis every 6-12 months. Submit renewal documentation 10-14 days before expiration via Aetna's provider portal, including updated clinical status, treatment response logs, and specialist attestation referencing CPB 0241 criteria. Standard review

How to Get Vitrakvi (Larotrectinib) Covered by Cigna in Michigan: Complete PA Guide and Appeal Scripts

Answer Box: Getting Vitrakvi Covered by Cigna in Michigan Vitrakvi (larotrectinib) requires prior authorization from Cigna for NTRK fusion-positive solid tumors that are metastatic or unresectable. Submit PA via CoverMyMeds or Evicore with molecular pathology report confirming NTRK fusion, oncologist prescription, and tumor staging documentation. If denied, Michigan residents have

How to Get Kesimpta (ofatumumab) Covered by Humana in North Carolina: Complete Prior Authorization and Appeal Guide

Quick Answer: Getting Kesimpta Approved by Humana in North Carolina Kesimpta (ofatumumab) requires prior authorization from Humana Medicare Advantage plans in North Carolina, typically at Tier 5 specialty coverage. Your fastest path to approval: Have your neurologist submit a PA request with documentation of relapsing MS diagnosis, hepatitis B screening,