Topic

Insurance Approval

A collection of 765 issues

Myths vs. Facts: Getting Idelvion (albutrepenonacog alfa; rFIX-FP) Covered by Aetna CVS Health in Georgia

Quick Answer: Idelvion requires prior authorization from Aetna CVS Health in Georgia. Success depends on complete documentation—factor IX levels, inhibitor testing, and clinical rationale—not just a prescription. If denied, you have 180 days for internal appeals and 60 days for Georgia's binding external review through the

How to Get Natpara Covered by UnitedHealthcare in Texas: Complete Guide to Prior Authorization and Appeals

Answer Box: Getting Natpara Covered by UnitedHealthcare in Texas Important Update: Natpara (parathyroid hormone) was discontinued by Takeda at the end of 2024, with no new commercial supply available. For patients currently on Natpara, work with your endocrinologist to transition to conventional therapy (calcium and vitamin D analogs) before existing

Myths vs. Facts: Getting Turalio (Pexidartinib) Covered by Humana in Pennsylvania

Answer Box: Getting Turalio Covered by Humana in Pennsylvania Turalio (pexidartinib) requires prior authorization under Humana Medicare Advantage plans in Pennsylvania for TGCT patients. Success depends on proper REMS enrollment, comprehensive medical necessity documentation, and understanding Pennsylvania's 50% external review success rate. Fastest path to approval: 1. Complete

If Ultomiris (Ravulizumab) Isn't Approved by UnitedHealthcare in Michigan: Formulary Alternatives & Exception Strategies

Quick Answer: Your Options When Ultomiris Is Denied If UnitedHealthcare denies Ultomiris (ravulizumab) in Michigan, you have three main paths: try a formulary alternative like Soliris (eculizumab), request a formulary exception with medical necessity documentation, or pursue a formal appeal. Your fastest option is often requesting a peer-to-peer review where

How to Get Imbruvica (ibrutinib) Covered by Aetna (CVS Health) in Florida: Prior Authorization Forms, Appeals, and Step-by-Step Guide

Answer Box: Getting Imbruvica Covered by Aetna (CVS Health) in Florida Aetna (CVS Health) requires prior authorization for Imbruvica (ibrutinib) in Florida, with step therapy typically requiring trial of acalabrutinib or zanubrutinib first. The fastest path to approval: (1) Confirm your diagnosis matches FDA-approved indications (CLL, SLL, Waldenström's,

How to Get Breyanzi (lisocabtagene maraleucel) Covered by Aetna CVS Health in Georgia: Forms, Appeals, and Success Strategies

Quick Answer: Getting Breyanzi Covered by Aetna CVS Health in Georgia Breyanzi (lisocabtagene maraleucel) requires prior authorization from Aetna CVS Health. Submit your request through the Availity provider portal or fax the completed PA form to 1-877-269-9916. You'll need documentation showing FDA-approved large B-cell lymphoma diagnosis, prior therapy

How to Get Onivyde (Irinotecan Liposome) Covered by Cigna in California: Prior Authorization, Appeals, and Cost Assistance

Answer Box: Getting Onivyde Covered by Cigna in California Onivyde (irinotecan liposome) requires prior authorization from Cigna and is typically covered as a Tier 5 specialty drug with copays ranging from $100-$500+ monthly. California residents have strong appeal rights through the Department of Managed Health Care (DMHC) with 50-65%

How to Get Pomalyst (pomalidomide) Covered by Aetna CVS Health in New Jersey: Complete Coding, Appeals, and Authorization Guide

Answer Box: Getting Pomalyst (pomalidomide) Covered by Aetna CVS Health in New Jersey Pomalyst requires prior authorization from Aetna CVS Health and strict REMS compliance. Key steps: 1) Ensure proper ICD-10 coding (C90.00 for active multiple myeloma), 2) Document prior lenalidomide and proteasome inhibitor failure, 3) Submit through CVS

Coding That Helps Get Vigabatrin (Sabril) Approved by Blue Cross Blue Shield in North Carolina: ICD-10, HCPCS, and NDC Guide

Answer Box: Get Vigabatrin Covered by Blue Cross Blue Shield in North Carolina Vigabatrin requires prior authorization from Blue Cross Blue Shield NC with specific coding requirements. Use ICD-10 code G40.821 (infantile spasms) or G40.219 (refractory complex partial seizures), include NDC numbers for billing, and ensure REMS program

Coding That Helps Get Orkambi (Lumacaftor/Ivacaftor) Approved by UnitedHealthcare in Florida: ICD-10, HCPCS, and NDC Requirements

Answer Box: Quick Path to Orkambi Coverage Getting Orkambi (lumacaftor/ivacaftor) covered by UnitedHealthcare in Florida requires specific coding and documentation. Use ICD-10 code E84.0-E84.9 for cystic fibrosis manifestations, submit genetic testing confirming F508del homozygous status, and ensure a CF specialist prescribes the medication. Submit prior authorization through