Counterforce Health (Page 36)

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How to Get Onivyde (Irinotecan Liposome) Covered by Cigna in California: Prior Authorization, Appeals, and Cost Assistance

Answer Box: Getting Onivyde Covered by Cigna in California Onivyde (irinotecan liposome) requires prior authorization from Cigna and is typically covered as a Tier 5 specialty drug with copays ranging from $100-$500+ monthly. California residents have strong appeal rights through the Department of Managed Health Care (DMHC) with 50-65%

How to Get Pomalyst (pomalidomide) Covered by Aetna CVS Health in New Jersey: Complete Coding, Appeals, and Authorization Guide

Answer Box: Getting Pomalyst (pomalidomide) Covered by Aetna CVS Health in New Jersey Pomalyst requires prior authorization from Aetna CVS Health and strict REMS compliance. Key steps: 1) Ensure proper ICD-10 coding (C90.00 for active multiple myeloma), 2) Document prior lenalidomide and proteasome inhibitor failure, 3) Submit through CVS

Coding That Helps Get Vigabatrin (Sabril) Approved by Blue Cross Blue Shield in North Carolina: ICD-10, HCPCS, and NDC Guide

Answer Box: Get Vigabatrin Covered by Blue Cross Blue Shield in North Carolina Vigabatrin requires prior authorization from Blue Cross Blue Shield NC with specific coding requirements. Use ICD-10 code G40.821 (infantile spasms) or G40.219 (refractory complex partial seizures), include NDC numbers for billing, and ensure REMS program

Don't Let the "No" Win: Your 5 Step Guide to Overturning Rheumatology Drug Denials

Getting a denial for a high-cost rheumatology drug (like a biologic) is frustrating, but it's often reversible. Insurance companies deny a significant share of prior authorization (PA) requests, yet studies show over 80% of these initial rejections are overturned on appeal. This guide provides an accessible, step-by-step action

Coding That Helps Get Orkambi (Lumacaftor/Ivacaftor) Approved by UnitedHealthcare in Florida: ICD-10, HCPCS, and NDC Requirements

Answer Box: Quick Path to Orkambi Coverage Getting Orkambi (lumacaftor/ivacaftor) covered by UnitedHealthcare in Florida requires specific coding and documentation. Use ICD-10 code E84.0-E84.9 for cystic fibrosis manifestations, submit genetic testing confirming F508del homozygous status, and ensure a CF specialist prescribes the medication. Submit prior authorization through

How to Get Humate-P Covered by Cigna in Illinois: Complete Prior Authorization and Appeals Guide

Answer Box: Fast Track to Approval Humate-P requires prior authorization from Cigna in Illinois. Submit the Hemophilia Factor VIII Prior Authorization Form through CoverMyMeds or fax to Accredo at 855-840-1678. Include: diagnosis confirmation, von Willebrand disease subtype documentation, and proof of desmopressin trial/failure (unless contraindicated for your VWD type)

How to Get Elelyso (taliglucerase alfa) Covered by Cigna in Florida: Complete Guide to Forms, Appeals & Approval

Answer Box: Getting Elelyso Covered by Cigna in Florida Fastest path to approval: Submit prior authorization through CoverMyMeds or ExpressPAth with confirmed Type 1 Gaucher disease diagnosis, specialist prescriber, and documentation of medical necessity. If denied, file internal appeal within 180 days, then external review through Florida Department of Financial

Renewing Fabrazyme (Agalsidase Beta) Approval with UnitedHealthcare in Michigan: 2025 Requirements and Timeline

Answer Box: Renewing Fabrazyme with UnitedHealthcare in Michigan Fabrazyme requires annual reauthorization with UnitedHealthcare, typically 12 months after initial approval. Start the renewal process 30 days before expiration to avoid coverage gaps. Submit updated clinical documentation showing treatment response through your provider's UnitedHealthcare portal or OptumRx system. If

Renewing Vimizim (Elosulfase Alfa) Approval with Blue Cross Blue Shield of Texas: 2025 Requirements & Timeline

Answer Box: Vimizim Renewal with Blue Cross Blue Shield of Texas Good news for HealthSelect members: As of September 2024, Blue Cross Blue Shield of Texas HealthSelect plans no longer require prior authorization for Vimizim (elosulfase alfa) renewals. However, you still need an in-network PCP referral on file. For other

UnitedHealthcare's Coverage Criteria for Gattex (Teduglutide) in Pennsylvania: What Counts as "Medically Necessary"?

Answer Box: Getting Gattex Covered by UnitedHealthcare in Pennsylvania UnitedHealthcare requires prior authorization for Gattex (teduglutide) with strict medical necessity criteria: documented short bowel syndrome, 12+ months of parenteral nutrition dependence (≥3 days/week), failed enteral optimization attempts, and recent colonoscopy with polyp removal. Fastest path to approval: Submit complete