Topic

California

A collection of 492 issues

How to Get Acthar Gel Approved by UnitedHealthcare in California: Prior Authorization Guide & Appeal Process

Answer Box: Getting Acthar Gel Covered by UnitedHealthcare in California UnitedHealthcare requires prior authorization for Acthar Gel (repository corticotropin injection) with strict medical necessity criteria limited to infantile spasms under age 2 and opsoclonus-myoclonus syndrome. Step therapy requiring documented failure of high-dose corticosteroids is mandatory for most conditions. If denied,

How to Get Revlimid (Lenalidomide) Covered by Humana in California: Timeline, Appeals, and State Protections

Quick Answer: Your Path to Revlimid Coverage Humana requires prior authorization for Revlimid (lenalidomide) in California, with standard decisions within 7 days and expedited reviews in 72 hours for urgent cases. Start by ensuring REMS compliance (prescriber and patient enrollment), then submit medical necessity documentation through your oncologist. If denied,

How to Get Jaypirca (Pirtobrutinib) Covered by Humana in California: Complete Guide to Prior Authorization, Appeals, and Specialty Pharmacy Requirements

Answer Box: Getting Jaypirca (Pirtobrutinib) Covered by Humana in California Jaypirca (pirtobrutinib) requires prior authorization from Humana and must be dispensed through a specialty pharmacy like CenterWell Specialty. To get approval: (1) Your oncologist submits a PA request via Humana's provider portal with documentation of prior BTK inhibitor

Do You Qualify for Arcalyst (rilonacept) Coverage by UnitedHealthcare in California? Decision Tree & Next Steps

Quick Answer: If you have CAPS, DIRA, or recurrent pericarditis and have failed colchicine/NSAIDs, you likely qualify for Arcalyst coverage through UnitedHealthcare in California. Submit prior authorization through your specialist with documented treatment failures. If denied, California's strong Independent Medical Review process overturns ~68% of specialty drug

Renewing Approval for Kalydeco (Ivacaftor) with Blue Cross Blue Shield in California: What to Prepare & When

Answer Box: Kalydeco Renewal Essentials Renew your Kalydeco (ivacaftor) authorization with Blue Cross Blue Shield of California 2-4 weeks before expiration. Submit via AuthAccel portal with updated clinic notes, liver function tests, FEV₁ data, and adherence documentation. Most renewals require proof of ongoing benefit (stable/improved lung function, reduced exacerbations)

How to Get Duopa (Carbidopa/Levodopa Enteral) Covered by Cigna in California: Prior Authorization Guide and Appeals Process

Answer Box: Cigna covers Duopa (carbidopa/levodopa enteral) with prior authorization for advanced Parkinson's disease patients experiencing motor fluctuations despite optimized oral therapy. Three steps to approval: 1) Your neurologist submits PA documentation showing failed oral carbidopa/levodopa trials and ≥3 hours daily OFF time, 2) Cigna reviews

How to Get Hemlibra (Emicizumab) Covered by Humana in California: Complete PA Guide & Appeal Scripts

Answer Box: Getting Hemlibra Covered by Humana in California Quick Path to Approval: Hemlibra (emicizumab-kxwh) requires prior authorization from Humana, with step therapy often requiring factor VIII trial first. Submit PA with factor VIII activity <1%, bleeding history, and inhibitor status. If denied, file internal appeal within 65 days,

How to Get Humira (adalimumab) Covered by Blue Cross Blue Shield in California: Complete Prior Authorization and Appeals Guide

Answer Box: Quick Path to Humira Coverage Blue Cross Blue Shield California requires prior authorization for Humira (adalimumab) with step therapy to preferred biosimilars like Hadlima. To get coverage: 1) Have your specialist submit a PA form with documented failure/intolerance of methotrexate and two preferred biologics, 2) Include TB/

How to Get Abecma (idecabtagene vicleucel) Covered by Blue Shield of California: Complete Timeline & Appeals Guide 2025

Answer Box: Getting Abecma Covered by Blue Shield California Blue Shield of California requires prior authorization for Abecma (idecabtagene vicleucel) with clinical review taking 24-72 hours for complete submissions. The fastest path: (1) Verify PA requirement via AuthAccel portal, (2) Submit complete clinical package including 4+ prior therapy lines and

How to Get Kesimpta (Ofatumumab) Covered by Blue Cross Blue Shield in California: Prior Authorization, Appeals & Cost Savings

Answer Box: Getting Kesimpta Covered by Blue Shield of California Kesimpta (ofatumumab) requires prior authorization from Blue Shield of California for relapsing multiple sclerosis. The fastest path to approval: 1) Submit PA request with MS diagnosis (ICD-10: G35) and documentation of failed/contraindicated alternatives like Betaseron or Copaxone, 2) Obtain