Topic

Insurance Approval

A collection of 657 issues

Myths vs. Facts: Getting Zolgensma Covered by Cigna in Pennsylvania (Complete Appeals Guide)

Answer Box: Getting Zolgensma Covered by Cigna in Pennsylvania Myth: If your doctor prescribes Zolgensma, Cigna automatically covers it. Fact: Prior authorization is mandatory, requiring genetic confirmation, anti-AAV9 antibody testing ≤1:50, and certified site-of-care documentation. In Pennsylvania, if denied, you have strong appeal rights—the state's external

Getting Palynziq (pegvaliase-pqpz) Covered by Humana in Georgia: Prior Authorization, Appeals, and Cost Assistance

Answer Box: Your Path to Coverage Palynziq (pegvaliase-pqpz) requires prior authorization from Humana and REMS program enrollment. Your fastest path: 1) Confirm your prescriber is REMS-certified and can document blood Phe >600 µmol/L, 2) Submit prior authorization through Humana's provider portal with complete PKU documentation, and

Coding That Helps Get Hetlioz LQ (Tasimelteon) Approved by Humana in Florida: ICD-10, NDC, and Billing Guide

Answer Box: Getting Hetlioz LQ Covered by Humana in Florida Hetlioz LQ (tasimelteon oral suspension) requires prior authorization from Humana Medicare Part D plans in Florida. The fastest path to approval: 1) Use ICD-10 code Q93.82 for Smith-Magenis syndrome with sleep disturbance codes (G47.0 for insomnia), 2) Submit

How to Get Gamifant (Emapalumab) Covered by Aetna in Ohio: Prior Authorization, Appeals & Step Therapy Guide

Answer Box: Getting Gamifant Covered by Aetna in Ohio Aetna covers Gamifant (emapalumab) for primary hemophagocytic lymphohistiocytosis (HLH) in Ohio when strict criteria are met. The fastest path to approval requires: (1) documenting primary HLH diagnosis using HLH-2004 criteria or genetic testing, (2) proving failure/intolerance to conventional therapy (etoposide

How to Get Xenpozyme (olipudase alfa-rpcp) Covered by Blue Cross Blue Shield in Virginia: Complete Timeline & Appeal Guide

Quick Answer: Getting Xenpozyme Covered by Blue Cross Blue Shield in Virginia Xenpozyme (olipudase alfa-rpcp) requires prior authorization from Blue Cross Blue Shield Virginia, typically decided within 72 hours for standard requests. To get approved: (1) Ensure you have documented ASMD diagnosis with genetic/enzyme confirmation, (2) Submit complete prior

How to Get Lumizyme (Alglucosidase Alfa) Covered by Humana in Georgia: PA Forms, Appeals & Timelines

Answer Box: Getting Lumizyme Covered by Humana in Georgia Lumizyme (alglucosidase alfa) requires prior authorization from Humana and is covered as a Tier 4 specialty drug. The fastest path to approval: 1) Have your specialist submit a prior authorization request with enzyme/genetic testing confirming Pompe disease, 2) Include documentation

How to Renew Epidiolex (Cannabidiol) Approval with Cigna in Florida: 2024 Requirements and Timeline

Answer Box: Renewing Epidiolex Approval with Cigna in Florida Cigna requires annual prior authorization renewal for Epidiolex in Florida, typically 30-60 days before your current approval expires. Your neurologist must submit documentation showing continued clinical benefit (≥30-50% seizure reduction from baseline), current diagnosis confirmation, and hepatic monitoring results. Cigna renders

How to Get Isturisa (Osilodrostat) Covered by Aetna CVS Health in Washington: Complete Guide with Forms and Appeals

Quick Answer: Getting Isturisa (Osilodrostat) Covered by Aetna CVS Health in Washington Aetna CVS Health requires prior authorization for Isturisa (osilodrostat) in Washington. The fastest path to approval: (1) Verify your endocrinologist has documented Cushing's disease with failed/contraindicated surgery, (2) Complete Aetna's specialty medication prior

How to Get Tavalisse (fostamatinib) Covered by UnitedHealthcare in New Jersey: Complete Guide with Forms and Appeal Scripts

Answer Box: Getting Tavalisse Covered by UnitedHealthcare in New Jersey Fastest Path to Approval: UnitedHealthcare requires prior authorization for Tavalisse (fostamatinib) with step therapy documentation. You'll need proof of failed corticosteroids and typically a thrombopoietin receptor agonist, plus platelet counts <30,000/μL documented by a hematologist.

How to Get Elzonris (tagraxofusp-erzs) Covered by Humana in New York: Appeals, Forms & State Protections

Answer Box: Getting Elzonris Covered by Humana in New York Fastest path to approval: Submit prior authorization with complete BPDCN pathology (CD123+ confirmation), capillary leak syndrome monitoring plan, and medical necessity letter citing failed alternatives. If denied, file internal appeal within 65 days, then external review through New York DFS