Topic

Pennsylvania

A collection of 499 issues

How to Get Xenpozyme (olipudase alfa-rpcp) Covered by Blue Cross Blue Shield in Pennsylvania: Complete Coding, Appeals, and Authorization Guide

Answer Box: Getting Xenpozyme Covered in Pennsylvania Xenpozyme (olipudase alfa-rpcp) requires prior authorization from Blue Cross Blue Shield plans in Pennsylvania. Use ICD-10 codes E75.240 (type A), E75.241 (type B), or E75.244 (type A/B) for ASMD diagnosis. Submit PA with genetic confirmation, baseline organ assessments, and

How to Get Tracleer (bosentan) Covered by Blue Cross Blue Shield in Pennsylvania: Complete Prior Authorization Guide

Answer Box: Getting Tracleer (bosentan) Covered in Pennsylvania Blue Cross Blue Shield plans in Pennsylvania require prior authorization for Tracleer (bosentan) with specific REMS program enrollment. The fastest path to approval: 1) Enroll prescriber and patient in the Bosentan REMS Program, 2) Submit PA request with PAH diagnosis confirmation and

How to Get Ocrevus (Ocrelizumab) Covered by Blue Cross Blue Shield in Pennsylvania: Complete Timeline and Appeals Guide

Answer Box: Getting Ocrevus Covered by Blue Cross Blue Shield in Pennsylvania Blue Cross Blue Shield Pennsylvania requires prior authorization for Ocrevus (ocrelizumab) with specific clinical criteria: confirmed MS diagnosis, age 18+, negative hepatitis B screening, and documentation of prior DMT trials or contraindications. Submit PA requests through your plan&

Getting Zanzalintinib (XL092) Covered by UnitedHealthcare in Pennsylvania: Clinical Trial Access and Compassionate Use Appeals Guide

Answer Box: Your Fastest Path to Zanzalintinib Coverage Getting Zanzalintinib (XL092) covered by UnitedHealthcare in Pennsylvania requires clinical trial enrollment or compassionate use approval, since this investigational TKI has no FDA approval. Your three options: (1) Enroll in an active STELLAR program trial where UnitedHealthcare covers routine monitoring costs, (2)

How to Get Gamifant (Emapalumab-lzsg) Covered by Blue Cross Blue Shield in Pennsylvania: Complete Timeline and Appeal Guide

Answer Box: Getting Gamifant Covered by Blue Cross Blue Shield in Pennsylvania Blue Cross Blue Shield requires prior authorization for Gamifant (emapalumab-lzsg) with documented HLH diagnosis using 5 of 8 HLH-2004 criteria OR genetic confirmation, plus failure/intolerance to conventional therapy (etoposide, dexamethasone, cyclosporine). Standard PA decisions take 14-30 days;

How to Get Somatuline Depot (Lanreotide) Covered by UnitedHealthcare in Pennsylvania: Complete Prior Authorization and Appeals Guide

Quick Answer: UnitedHealthcare requires prior authorization for Somatuline Depot (lanreotide) in Pennsylvania, typically under medical benefit (HCPCS J1930) with step therapy requiring prior octreotide trial. Submit PA via UHC Provider Portal with diagnosis confirmation, prior therapy records, and specialist documentation. If denied, file internal appeals within 65 days (Medicare Advantage)

How to Get Brineura (Cerliponase Alfa) Covered by Blue Cross Blue Shield in Pennsylvania: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Brineura Covered by Blue Cross Blue Shield in Pennsylvania Brineura (cerliponase alfa) requires prior authorization from Blue Cross Blue Shield plans in Pennsylvania, including Highmark and Independence Blue Cross. Coverage is approved for pediatric patients with confirmed CLN2 disease (TPP1 deficiency) when administered at specialized centers by

How to Get Qinlock (Ripretinib) Covered by Aetna CVS Health in Pennsylvania: Complete Prior Authorization and Appeals Guide

Quick Answer: Qinlock (ripretinib) requires prior authorization from Aetna CVS Health in Pennsylvania. You'll need documented failure of three prior kinase inhibitors (imatinib, sunitinib, regorafenib), submit through the CVS Caremark portal or CoverMyMeds, and allow 15 business days for standard review. If denied, Pennsylvania's new external

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

Answer Box: Getting Oxlumo Covered by Cigna in Pennsylvania Cigna requires prior authorization for Oxlumo (lumasiran) with genetic confirmation of PH1, elevated urinary oxalate levels, and prescription by a nephrologist or urologist. Submit PA through CoverMyMeds or EviCore portal with AGXT mutation results and baseline labs. If denied, use Cigna&

How to Get Blenrep (belantamab mafodotin) Covered by Aetna (CVS Health) in Pennsylvania: Appeals Guide with Forms and Timelines

Answer Box: Getting Blenrep Covered in Pennsylvania Blenrep (belantamab mafodotin) received FDA approval on October 23, 2025, for adults with relapsed or refractory multiple myeloma. Aetna (CVS Health) requires prior authorization through CVS Caremark for this specialty drug. If denied, Pennsylvania's external review program overturns approximately 50% of