Topic

Insurance Approval

A collection of 610 issues

Getting Prolastin-C Covered by Blue Cross Blue Shield of Michigan: PA Requirements, Appeals, and State Protections (2024-2025)

Answer Box: How to Get Prolastin-C Covered by BCBS Michigan Blue Cross Blue Shield of Michigan requires prior authorization for Prolastin-C (alpha1-proteinase inhibitor) for commercial members, with specific criteria including confirmed alpha-1 antitrypsin deficiency, nonsmoker status, and symptomatic emphysema. Medicare Plus Blue and BCN Advantage members don't need

How to Get Zolgensma (Onasemnogene Abeparvovec) Covered by Humana in North Carolina: Complete Prior Authorization Guide

Quick Answer: Humana requires prior authorization for Zolgensma (onasemnogene abeparvovec) in North Carolina with strict age (<2 years), genetic testing, and clinical documentation requirements. Submit through Humana's provider portal with complete SMN1 testing, anti-AAV9 titers, and specialist consultation. If denied, use North Carolina's Smart NC

How to Get Eylea and Lucentis Covered by Cigna in Ohio: Complete Coding, Appeals, and Authorization Guide

Answer Box: Getting Eylea/Lucentis Covered by Cigna in Ohio Cigna requires prior authorization for Eylea (aflibercept) and Lucentis (ranibizumab) in Ohio, typically mandating bevacizumab (Avastin) step therapy first. Submit PA requests via CoverMyMeds or fax to 1-866-873-8279 with complete ICD-10 codes (H35.32_ for wet AMD, E11.3_ for

How to Get Soliris (Eculizumab) Covered by Humana in Pennsylvania: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Soliris (Eculizumab) Covered by Humana in Pennsylvania Yes, Humana covers Soliris (eculizumab) in Pennsylvania, but requires strict prior authorization. The medication typically falls under Tier 5 (specialty tier) with 25-33% coinsurance. Your fastest path to approval: 1) Ensure meningococcal vaccination is completed at least 2 weeks before

How to Get Rinvoq (upadacitinib) Covered by Blue Cross Blue Shield of Michigan: Prior Authorization, Appeals, and Cost-Saving Strategies

Answer Box: Getting Rinvoq Covered in Michigan Rinvoq (upadacitinib) requires prior authorization from Blue Cross Blue Shield of Michigan and is typically covered as a preferred alternative for autoimmune conditions like rheumatoid arthritis and ulcerative colitis. Your fastest path to approval: 1. Confirm formulary status: Rinvoq is covered but requires

How to Get Revcovi (Elapegademase) Covered by Aetna (CVS Health) in Washington: Complete Appeals Guide

Answer Box: Getting Revcovi Covered by Aetna in Washington Revcovi (elapegademase) requires prior authorization from Aetna (CVS Health). To get coverage in Washington: (1) Your immunologist submits a PA request with ADA-SCID genetic confirmation and documentation of failed/contraindicated bone marrow transplant, (2) If denied, file internal appeal within 30-60

Renewing Gattex (Teduglutide) Approval with Cigna in New Jersey: Complete Guide to Documentation and Deadlines

Quick Answer: Cigna requires specific renewal documentation for Gattex (teduglutide) including proof of reduced parenteral nutrition needs, lab results from the past 6 months (bilirubin, alkaline phosphatase, lipase, amylase), and colonoscopy documentation if you've been on therapy for over a year. Contact Accredo specialty pharmacy 2 weeks before

How to Get Emgality (Galcanezumab) Approved by Cigna in Illinois: Complete Timeline & Appeals Guide

Answer Box: Getting Emgality Approved by Cigna in Illinois Cigna requires prior authorization for Emgality (galcanezumab) with documented failure of both topiramate and a beta blocker before approval. Standard PA decisions take 7 business days, expedited reviews 72 hours. Illinois law requires internal appeals within 30 days and external review

How to Get Oxlumo (Lumasiran) Covered by Humana in Washington: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Oxlumo (Lumasiran) Covered by Humana in Washington Oxlumo requires prior authorization from Humana for primary hyperoxaluria type 1 (PH1). The fastest path to approval: (1) Confirm PH1 diagnosis with genetic testing showing AGXT mutations or liver enzyme analysis, (2) Document elevated urinary oxalate levels (>0.7

How to Get Arcalyst (Rilonacept) Covered by Aetna in Texas: Complete Appeal Guide with Forms and Timelines

Quick Answer: Getting Arcalyst Covered by Aetna in Texas Arcalyst (rilonacept) requires prior authorization from Aetna for CAPS, DIRA, or recurrent pericarditis. First step: Have your cardiologist or rheumatologist submit a PA request with diagnosis confirmation, failed prior therapies (colchicine/NSAIDs for pericarditis), and elevated inflammatory markers. If denied, you