Topic

Insurance Approval

A collection of 5314 issues

Renewing Orfadin (nitisinone) Approval with Aetna (CVS Health) in New Jersey: Timeline, Documentation & Appeal Process

Answer Box: Key Steps for Orfadin Renewal Success Orfadin (nitisinone) is excluded from Aetna's 2025 specialty formulary, requiring a formulary exception for any coverage. Start renewal 60-90 days early with updated labs (succinylacetone, tyrosine levels, liver function tests), metabolic specialist notes documenting treatment response, and dietary compliance records.

Work With Your Doctor to Get Kuvan (Sapropterin) Approved by Blue Cross Blue Shield in Washington: Complete Prior Authorization Guide

Answer Box: Getting Kuvan Covered in Washington Kuvan (sapropterin dihydrochloride) requires prior authorization from Premera Blue Cross in Washington for PKU treatment. Success depends on strong provider collaboration documenting: confirmed PKU diagnosis, elevated phenylalanine levels despite dietary management, and BH4 responsiveness testing showing ≥30% phenylalanine reduction. Fastest path: Schedule a

How to Get Waylivra (Volanesorsen) Covered by Humana in Washington: Complete Guide with Forms and Appeals

Answer Box: Getting Waylivra Covered by Humana in Washington Waylivra (volanesorsen) requires prior authorization from Humana as it's not FDA-approved in the US. Coverage depends on confirmed familial chylomicronemia syndrome (FCS) with triglycerides ≥880 mg/dL, genetic testing, and specialist prescription. First step: Have your lipidologist submit a

Myths vs. Facts: Getting Uplizna (Inebilizumab) Covered by UnitedHealthcare in California

Quick Answer: UnitedHealthcare requires prior authorization for Uplizna (inebilizumab) in California with specific documentation: AQP4-positive NMOSD diagnosis, neurologist prescription, HBV screening, and often step therapy with eculizumab first. If denied, file internal appeal within 180 days, then California's Independent Medical Review (IMR) through DMHC. Start by gathering AQP4-IgG

How to Get Kymriah Covered by Blue Cross Blue Shield in New Jersey: Complete PA Guide with Forms and Appeal Scripts

Quick Start: Get Kymriah Covered by Blue Cross Blue Shield in New Jersey Getting Kymriah (tisagenlecleucel) covered by Horizon Blue Cross Blue Shield of New Jersey requires prior authorization through their medical policy CC-06005. Your oncologist must document CD19-positive B-cell ALL or eligible lymphoma, failed prior therapies, and treatment at

How to Get Nucala (Mepolizumab) Covered by Cigna in New Jersey: Complete Forms, Appeals, and Contact Guide

Answer Box: Getting Cigna Coverage for Nucala in New Jersey Cigna requires prior authorization for Nucala (mepolizumab) with specific clinical criteria including blood eosinophil levels ≥300 cells/μL within 6 weeks and documented failure of high-dose inhaled corticosteroids plus LABA therapy. Submit requests via CoverMyMeds or Cigna's provider

How to Get Luxturna (voretigene neparvovec-rzyl) Covered by Humana in Washington: Forms, Appeals, and Resources

Answer Box: Getting Luxturna Covered by Humana in Washington Luxturna requires prior authorization (PA) from Humana Medicare Advantage plans in 2024-2025. To get approved in Washington: 1) Submit the "Request for Medicare Prescription Drug Coverage Determination" form via CoverMyMeds portal or fax to 877-486-2621, 2) Include confirmed biallelic

How to Get Arikayce Covered by Blue Cross Blue Shield in New York: Prior Authorization Forms, Appeal Scripts, and External Review

Quick Answer: Getting Arikayce Covered by Blue Cross Blue Shield in New York Blue Cross Blue Shield of New York requires prior authorization for Arikayce (amikacin liposome inhalation) for refractory MAC lung disease. Submit PA via Availity Essentials with proof of 6+ months failed combination therapy and positive sputum cultures.

How to Get Koselugo (Selumetinib) Covered by Cigna in New York: Complete Guide with Forms, Appeals, and Timelines

Answer Box: Getting Koselugo (Selumetinib) Covered by Cigna in New York Cigna requires prior authorization for Koselugo (selumetinib) in pediatric patients ≥2 years with NF1-related plexiform neurofibromas. Initial approval lasts 12 months with documented baseline LVEF and ophthalmologic evaluation. First step: Have your oncologist submit PA through Cigna's

How to Get Revlimid (Lenalidomide) Covered by Blue Cross Blue Shield in Virginia: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Revlimid Covered by Blue Cross Blue Shield in Virginia Blue Cross Blue Shield of Virginia requires prior authorization for Revlimid (lenalidomide), with approval depending on FDA-approved indications like multiple myeloma, documented prior treatment failures, and enrollment in the mandatory Lenalidomide REMS program. Your oncologist must submit clinical