Topic

California

A collection of 402 issues

How to Get Upstaza (Eladocagene Exuparvovec) Covered by Humana in California: Complete Coding and Appeals Guide

Answer Box: Getting Upstaza Covered by Humana in California Upstaza (eladocagene exuparvovec) is covered under Medicare Part B as a physician-administered gene therapy. For Humana Medicare Advantage in California, you'll need prior authorization with genetic confirmation of AADC deficiency, treatment at a certified neurosurgical center, and comprehensive clinical

How to Get Isturisa (Osilodrostat) Covered by Blue Cross Blue Shield in California: Prior Authorization, Appeals, and Cost Assistance

Answer Box: Getting Isturisa Covered by Blue Cross Blue Shield in California To get Isturisa (osilodrostat) covered by Blue Cross Blue Shield in California, you'll need prior authorization with specific documentation: endocrinologist consultation, confirmed Cushing's disease diagnosis with elevated urinary free cortisol (UFC), and evidence that

How to Get Increlex (mecasermin) Covered by Humana in California: Forms, Appeals Timeline & PA Requirements

Answer Box: Getting Increlex Covered by Humana in California Eligibility: Children ≥2 years with severe primary IGF-1 deficiency (height ≤-3.0 SD, low IGF-1, normal/elevated GH) prescribed by pediatric endocrinologist. Fastest Path: Submit prior authorization with comprehensive lab results, growth charts, and medical necessity letter through Humana's

How to Get Busulfex (busulfan injection) Covered by Blue Cross Blue Shield in California: Appeals Guide & Templates

Answer Box: Getting Busulfex Covered in California If Blue Cross Blue Shield denied coverage for Busulfex (busulfan injection), you have strong appeal rights in California. First step: File an internal appeal within 60 days using supporting documentation from your transplant team. Fastest path: Request a peer-to-peer review between your hematologist

How to Get Juxtapid (lomitapide) Covered by Blue Shield of California: Forms, Appeals, and Authorization Guide 2025

Answer Box: Getting Juxtapid Covered by Blue Shield of California Juxtapid (lomitapide) requires prior authorization from Blue Shield of California for homozygous familial hypercholesterolemia (HoFH). The fastest path: (1) Confirm genetic/clinical HoFH diagnosis with LDL-C ≥400 mg/dL or total cholesterol >500 mg/dL, (2) Document failed trials

Blue Cross Blue Shield California's Coverage Criteria for Brineura (Cerliponase Alfa): What Counts as "Medically Necessary"?

Answer Box: Getting Brineura Covered by Blue Cross Blue Shield California To get Brineura (cerliponase alfa) covered by Blue Cross Blue Shield California, you need: 1. Confirmed CLN2 diagnosis with TPP1 enzyme deficiency or genetic testing showing two pathogenic variants 2. Age 3+ with ambulatory function (able to walk with

How to Get Enhertu (fam-trastuzumab deruxtecan-nxki) Covered by Blue Cross Blue Shield in California: Complete Prior Authorization and Appeal Guide

Answer Box: Getting Enhertu Covered by Blue Cross Blue Shield in California Enhertu (fam-trastuzumab deruxtecan-nxki) requires prior authorization from Blue Cross Blue Shield plans in California. Success depends on documented HER2-positive status, line-of-therapy criteria, and addressing interstitial lung disease (ILD) monitoring requirements. If denied, California's Independent Medical Review

How to Get Xyrem (Sodium Oxybate) Covered by Aetna (CVS Health) in California: Complete 2025 Guide

Quick Answer: Getting Xyrem Covered by Aetna (CVS Health) in California Yes, Aetna covers Xyrem with prior authorization. You'll need REMS enrollment first, then submit PA with sleep study results and documented stimulant/modafinil failures. Standard approval takes 15 business days. If denied, California's Independent Medical

The Complete Guide to Getting Jynarque (Tolvaptan) Covered by UnitedHealthcare in California: Requirements, Forms & Appeal Scripts

Answer Box: Getting Jynarque Covered by UnitedHealthcare in California Fastest path to approval: UnitedHealthcare requires prior authorization for Jynarque but has no step therapy requirement as of 2024. You need ADPKD diagnosis documentation, REMS enrollment completion, and baseline liver function tests. If denied, California's Independent Medical Review (IMR)

How to Get Kanuma (Sebelipase Alfa) Covered by Blue Cross Blue Shield in California: Complete Prior Authorization and Appeal Guide

Quick Answer: Getting Kanuma Covered by Blue Cross Blue Shield in California Kanuma (sebelipase alfa) requires prior authorization from Blue Cross Blue Shield plans in California. To secure approval: (1) Confirm LAL-D diagnosis with enzyme activity testing and genetic confirmation, (2) Document hepatic abnormalities and lipid profile showing disease severity,