Topic

California

A collection of 417 issues

How to Get Ilaris (Canakinumab) Covered by Humana in California: Prior Authorization Guide and Appeal Process

Quick Answer: Getting Ilaris (Canakinumab) Covered by Humana in California Humana requires prior authorization for Ilaris (canakinumab) with step therapy documentation and medical necessity justification. If denied, California residents have strong appeal rights through the DMHC Independent Medical Review (IMR) process with a 73% success rate. Start today: Have your
5 min read

How to Get Evrysdi (risdiplam) Covered by Aetna (CVS Health) in California: Prior Authorization, Appeals, and State Protections

Answer Box: Getting Evrysdi Covered in California Getting Evrysdi (risdiplam) covered by Aetna (CVS Health) in California requires prior authorization with genetic confirmation of SMA, baseline motor assessments, and specialist prescription. If denied, California's robust appeal protections give you strong reversal odds—about 68% of specialty drug appeals
6 min read

Lowering Out-of-Pocket for Thiola / Thiola EC (tiopronin) with UnitedHealthcare in California: Copay, Tiering & Assistance

Answer Box: Getting Thiola Covered by UnitedHealthcare in California Fastest path to approval: UnitedHealthcare requires prior authorization for Thiola/Thiola EC with documented cystinuria diagnosis (ICD-10 E72.01), 24-hour urine cystine >250mg/day, specialist involvement, and failed conservative therapy. Submit through OptumRx portal with complete clinical documentation. If denied,
6 min read

How to Get Onpattro (Patisiran) Covered by UnitedHealthcare in California: Complete Coding, Appeals, and IMR Guide

Answer Box: Getting Onpattro (Patisiran) Covered by UnitedHealthcare in California Onpattro (patisiran) requires prior authorization from UnitedHealthcare OptumRx for hereditary transthyretin amyloidosis polyneuropathy (hATTR-PN). Key requirements: genetic confirmation of pathogenic TTR mutation, neurologist evaluation, and proper ICD-10 coding (E85.1). If denied, file internal appeal within 60 days, then escalate
5 min read

How to Get Juxtapid (lomitapide) Covered by Humana in California: Prior Authorization, Appeals, and Cost Assistance

Answer Box: Getting Juxtapid (lomitapide) Covered by Humana in California Juxtapid requires prior authorization from Humana with strict clinical documentation. Key requirements include genetic confirmation of homozygous familial hypercholesterolemia (HoFH), documented failure or intolerance to maximum-dose statins and ezetimibe, enrollment in the REMS program, and dispensing through certified specialty pharmacies
7 min read

How to Get Koselugo (Selumetinib) Covered by Blue Cross Blue Shield in California: Prior Authorization Guide and Appeal Scripts

Answer Box: Getting Koselugo Covered by Blue Cross Blue Shield in California Koselugo (selumetinib) requires prior authorization from Blue Cross Blue Shield in California but is generally covered when FDA criteria are met. The fastest path: 1) Gather NF1 diagnosis, imaging showing inoperable plexiform neurofibromas, and baseline cardiac/eye exams,
6 min read