Topic

Illinois

A collection of 418 issues

How to Get Symdeko/Symkevi (Tezacaftor/Ivacaftor) Covered by Humana in Illinois: Complete Appeals Guide with Forms and Timelines

Answer Box: Getting Symdeko/Symkevi Covered by Humana in Illinois Humana typically requires prior authorization for Symdeko/Symkevi (tezacaftor/ivacaftor) and often classifies it as non-formulary, requiring a formulary exception. To get coverage in Illinois: (1) Submit a complete prior authorization with CF diagnosis, CFTR genotype showing F508del mutation, age

How to Get Tegsedi (Inotersen) Covered by Aetna CVS Health in Illinois: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Tegsedi (Inotersen) Covered by Aetna CVS Health in Illinois Tegsedi (inotersen) requires prior authorization from Aetna CVS Health for hATTR polyneuropathy coverage in Illinois. Key requirements: confirmed TTR gene mutation, documented polyneuropathy symptoms, specialist prescription (neurologist/geneticist), and REMS program enrollment. Submit via Aetna provider portal with

How to Get Vitrakvi (larotrectinib) Covered by Blue Cross Blue Shield of Illinois: PA Forms, Appeal Scripts & NTRK Testing Requirements

Answer Box: Getting Vitrakvi Covered by BCBS Illinois Blue Cross Blue Shield of Illinois (BCBSIL) requires prior authorization for Vitrakvi (larotrectinib), which is not on their 2025 formulary. Your fastest path to approval: (1) Submit a complete PA request with validated NTRK fusion testing results, (2) Include medical necessity documentation

How to Get Stelara (Ustekinumab) Covered by UnitedHealthcare in Illinois: Complete 2025 Guide to Prior Authorization, Appeals, and Biosimilar Requirements

Answer Box: Getting Stelara Covered by UnitedHealthcare in Illinois UnitedHealthcare requires prior authorization for Stelara (ustekinumab) in Illinois, with most commercial plans now requiring biosimilar trials first. As of 2025, brand Stelara is non-formulary; patients must try Steqeyma or Yesintek unless documenting allergy/intolerance or clinical failure after 6+ weeks

Getting Blenrep (Belantamab Mafodotin) Covered by UnitedHealthcare in Illinois: PA Requirements, Appeals, and Cost Support

Answer Box: Getting Blenrep Covered by UnitedHealthcare in Illinois Important Update: Blenrep (belantamab mafodotin) was voluntarily withdrawn from the U.S. market in 2022. GSK resubmitted for FDA approval with a PDUFA date of October 23, 2025. Currently, access is limited to clinical trials or expanded access programs only. For

If Xembify Isn't Approved by Cigna in Illinois: Formulary Alternatives & Exception Paths

Answer Box: When Cigna Denies Xembify in Illinois If Cigna denies Xembify (immune globulin, SC) for primary immunodeficiency in Illinois, you have alternatives. Covered options typically include Hizentra (SCIG), Gamunex-C (IVIG/SCIG), and Privigen (IVIG) under Cigna's immune globulin policy. First step: Request formulary exception through your prescriber,

How to Get Gamifant (Emapalumab-lzsg) Covered by UnitedHealthcare in Illinois: Prior Authorization Guide 2025

Answer Box: Getting Gamifant Approved by UnitedHealthcare in Illinois UnitedHealthcare requires prior authorization for Gamifant (emapalumab-lzsg) as a medical-benefit specialty drug for primary HLH. Key requirements: confirmed HLH-2004 diagnostic criteria (≥5 of 8 criteria or genetic confirmation), documented failure of conventional therapy (dexamethasone + etoposide), and FDA-label dosing plan. Submit via

Humana's Coverage Criteria for Besponsa (Inotuzumab Ozogamicin) in Illinois: What Counts as "Medically Necessary"?

Answer Box: Getting Besponsa (Inotuzumab Ozogamicin) Covered by Humana in Illinois Humana Medicare Advantage requires prior authorization for Besponsa through their specialty oncology vendor Evolent Health. Medical necessity requires: CD22-positive B-cell precursor ALL, relapsed/refractory status, prior therapy failures documented, and hepatic monitoring plan. Submit PA via Evolent portal or

How to Get Dojolvi (Triheptanoin) Covered by Humana in Illinois: Complete Prior Authorization Guide

Answer Box: To get Dojolvi (triheptanoin) covered by Humana in Illinois, you need prior authorization with molecular confirmation of LC-FAOD, discontinuation of other MCT products, and specialist prescribing. Submit through Humana's Prior Authorization Search Tool, expect 7-30 day decisions, and use Illinois' 65-day Medicare appeal window if

Getting Daybue (Trofinetide) Covered by Humana in Illinois: Complete Prior Authorization and Appeals Guide

Answer Box: Quick Path to Daybue Coverage with Humana in Illinois Yes, Humana covers Daybue (trofinetide) for Rett syndrome with prior authorization. You'll need confirmed MECP2 genetic testing, specialist documentation, and weight-based dosing justification. The fastest path: have your neurologist submit Humana's PA form with genetic