Topic

North Carolina

A collection of 504 issues

Denied for Stelara by Blue Cross Blue Shield in North Carolina? Complete Appeals Guide (Forms, Timelines & Scripts)

Answer Box: Getting Stelara Covered by Blue Cross Blue Shield in North Carolina Blue Cross Blue Shield of North Carolina requires prior authorization for Stelara (ustekinumab), typically with step therapy requirements. If denied, you have strong appeal rights through North Carolina's Smart NC program. Fastest path: Submit a

How to Get Opfolda (miglustat) Covered by Blue Cross Blue Shield North Carolina: Complete Appeals Guide with Forms and Timelines

Answer Box: Getting Opfolda Covered by Blue Cross Blue Shield NC Opfolda (miglustat) requires prior authorization from Blue Cross Blue Shield North Carolina and must be used with Pombiliti for adult LOPD patients ≥40 kg who haven't improved on standard ERT for ≥1 year. First step today: Call

How to Get Pyrukynd (mitapivat) Covered by Aetna (CVS Health) in North Carolina: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Pyrukynd (mitapivat) Covered by Aetna (CVS Health) in North Carolina Pyrukynd (mitapivat) is non-formulary on Aetna plans and requires prior authorization with strict genetic and clinical criteria. You'll need confirmed pyruvate kinase deficiency (≥2 PKLR variants with ≥1 missense), hemoglobin ≤10 g/dL or significant

How to Get Procysbi (Cysteamine Bitartrate DR) Covered by Cigna in North Carolina: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Procysbi Covered by Cigna in North Carolina Cigna typically requires prior authorization for Procysbi (cysteamine bitartrate DR), often with step therapy requiring immediate-release cysteamine first. The fastest path: have your specialist submit a complete PA packet including nephropathic cystinosis diagnosis (ICD-10 E72.04), WBC cystine monitoring plan,

How to Get Cresemba (isavuconazole) Covered by Humana in North Carolina: Prior Authorization Guide and Appeal Process

Answer Box: Getting Cresemba Covered by Humana in North Carolina Cresemba (isavuconazole) requires prior authorization from Humana and is typically placed on Tier 4 (Specialty) with higher cost-sharing. To get approval: 1) Confirm your diagnosis of invasive aspergillosis or mucormycosis with culture/biopsy results, 2) Submit Humana's coverage

Myths vs. Facts: Getting Aldurazyme (laronidase) Covered by UnitedHealthcare in North Carolina

Answer Box: Getting Aldurazyme Covered by UnitedHealthcare in North Carolina Eligibility: UnitedHealthcare requires prior authorization for Aldurazyme (laronidase) with confirmed MPS I diagnosis through enzymatic testing and genetic confirmation. Fastest path: Have your MPS specialist submit complete PA documentation including IDUA enzyme deficiency results, genetic testing, and baseline clinical assessments.

Myths vs. Facts: Getting Opsumit (Macitentan) Covered by Humana in North Carolina

Answer Box: Humana Medicare Advantage members in North Carolina cannot use Smart NC external review and must follow federal Medicare appeals. Commercial Humana plan members may qualify for Smart NC's free external review process. For Opsumit (macitentan), expect prior authorization requiring WHO Group 1 PAH diagnosis, specialist prescriber,

How to Get Kesimpta (Ofatumumab) Covered by Cigna in North Carolina: Complete PA Guide with Appeals Process

Answer Box: Getting Kesimpta Covered by Cigna in North Carolina Fastest path to approval: Verify Kesimpta requires prior authorization through your Cigna plan, have your neurologist submit the Multiple Sclerosis CCRD Prior Authorization Form via CoverMyMeds or Surescripts ePA, and designate Accredo Specialty Pharmacy for dispensing. If denied, file internal

Coding That Helps Get Rebif (Interferon Beta-1a) Approved by Aetna CVS Health in North Carolina: ICD-10, HCPCS, and NDC Guide

Answer Box: Getting Rebif Approved in North Carolina Rebif (interferon beta-1a) requires prior authorization from Aetna CVS Health in North Carolina. The fastest approval path: (1) Use correct ICD-10 code G35.A for relapsing-remitting MS with documented disease activity, (2) Submit complete prior authorization through CVS Specialty with step therapy

Renewing Soliris (Eculizumab) Coverage with Blue Cross Blue Shield in North Carolina: Complete Timeline and Documentation Guide

Answer Box: Soliris (eculizumab) requires annual reauthorization with Blue Cross Blue Shield of North Carolina. Start renewal 30-60 days before expiration by gathering updated labs (LDH, hemoglobin, platelets), clinical response documentation, and current vaccination records. Submit through Blue e or your specialty pharmacy. If denied, use Smart NC external review—