Topic

California

A collection of 427 issues

UnitedHealthcare's Coverage Criteria for Elzonris (Tagraxofusp-erzs) in California: What Counts as "Medically Necessary"?

Answer Box: Getting Elzonris Covered by UnitedHealthcare in California UnitedHealthcare requires prior authorization for Elzonris (tagraxofusp-erzs) with strict medical necessity criteria. Key requirements include confirmed CD123-positive BPDCN diagnosis, capillary leak syndrome monitoring plan, and inpatient initiation. If denied, California's Independent Medical Review (IMR) has a 68% success rate

How to Get Tepezza (Teprotumumab) Covered by Aetna CVS Health in California: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Tepezza Covered by Aetna CVS Health in California Tepezza (teprotumumab) requires prior authorization from Aetna CVS Health for thyroid eye disease (TED). You'll need documentation of moderate-to-severe TED, specialist evaluation, and prior treatment failures. If denied, California's Independent Medical Review (IMR) has a

How to Get Arikayce (Amikacin Liposome Inhalation) Covered by Blue Cross Blue Shield in California: Appeals Guide with Forms and Timelines

Answer Box: Getting Arikayce Covered by Blue Cross Blue Shield California Blue Cross Blue Shield California requires prior authorization for Arikayce (amikacin liposome inhalation) for MAC lung disease. You must be 18+ with documented refractory MAC after 6+ months of combination therapy. If denied, file an internal appeal within 180

How to Get Evrysdi (Risdiplam) Covered by Humana in California: Prior Authorization, Appeals, and Step Therapy Guide

Answer Box: Getting Evrysdi Covered by Humana in California Evrysdi (risdiplam) requires prior authorization from Humana and is typically placed on a specialty drug tier with higher cost-sharing. To get approved: (1) Submit genetic confirmation of 5q SMA with SMN1 deletion, (2) Document baseline motor assessments and prior therapy history,

How to Get Fintepla (Fenfluramine) Covered by Cigna in California: ICD-10 Codes, REMS Documentation, and Appeals Process

Answer Box: Getting Fintepla Covered by Cigna in California Fast Track to Approval: Cigna requires prior authorization for Fintepla (fenfluramine) with documented Dravet syndrome (ICD-10: G40.83) or Lennox-Gastaut syndrome (G40.81), REMS enrollment with baseline echocardiogram, and failure of at least two preferred anti-seizure medications. First step today: Gather

Getting Tavalisse (Fostamatinib) Covered by Cigna in California: Complete Guide to Prior Authorization and Appeals

Answer Box: Your Fastest Path to Tavalisse Coverage To get Tavalisse (fostamatinib) covered by Cigna in California: You need documented failure of prior ITP therapies (steroids, IVIG, TPO receptor agonists), a hematologist's prescription, and current platelet counts <30,000/μL. Submit prior authorization through Cigna's

How to Get Kineret (anakinra) Covered by Cigna in California: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Kineret (anakinra) Covered by Cigna in California Kineret requires prior authorization from Cigna for both rheumatoid arthritis and NOMID. Your fastest path: 1) Have your rheumatologist submit a PA through CoverMyMeds or Accredo's portal documenting failed TNF inhibitors and infection screening, 2) If denied, file

How to Get Translarna (Ataluren) Covered by Cigna in California: Complete Prior Authorization Guide

Answer Box: Getting Translarna (Ataluren) Covered by Cigna in California Translarna (ataluren) is not FDA-approved but may be available through expanded access programs. For Cigna coverage in California: (1) Submit prior authorization via Cigna's California-specific form to fax 1-866-873-8279, (2) Include genetic testing confirming nonsense mutation DMD and

Get Poteligeo (Mogamulizumab) Covered by Aetna CVS Health in California: Complete Guide to Prior Authorization and Appeals

Answer Box: Quick Path to Approval Yes, Poteligeo (mogamulizumab-kpkc) can be covered by Aetna CVS Health in California with proper prior authorization. The drug requires documentation of relapsed/refractory mycosis fungoides or Sézary syndrome after ≥1 prior systemic therapy. Your fastest path: 1) Have your dermatology-oncology specialist submit a complete

Blue Cross Blue Shield California Crysvita (Burosumab) Coverage: Prior Authorization Requirements and Appeal Process

Answer Box: Getting Crysvita Covered by Blue Cross Blue Shield California To get Crysvita (burosumab) approved by Blue Cross Blue Shield California, you need: (1) documented XLH or TIO diagnosis with biochemical confirmation, (2) specialist prescription from endocrinologist or nephrologist, and (3) prior authorization through their specialty pharmacy network. For