Topic

Virginia

A collection of 238 issues

Myths vs. Facts: Getting Mavenclad (Cladribine Tablets) Covered by UnitedHealthcare in Virginia

Answer Box: Getting Mavenclad Covered by UnitedHealthcare in Virginia UnitedHealthcare requires prior authorization and step therapy for Mavenclad (cladribine tablets) in Virginia. You must try at least one preferred MS therapy first unless medically contraindicated. Key requirements: confirmed relapsing MS diagnosis, baseline lymphocyte count, negative pregnancy test (if applicable), and

How to Get Abecma (idecabtagene vicleucel) Covered by Aetna CVS Health in Virginia: Timeline, Appeals, and State Protections

Answer Box: Getting Abecma Covered by Aetna CVS Health in Virginia Aetna CVS Health covers Abecma (idecabtagene vicleucel) for relapsed/refractory multiple myeloma after ≥2 prior lines including an immunomodulatory agent, proteasome inhibitor, and anti-CD38 antibody. Prior authorization is required and typically takes 14-30 days (72 hours if urgent). First

How to Get Palynziq (pegvaliase-pqpz) Covered by Blue Cross Blue Shield in Virginia: Complete Guide with ICD-10, HCPCS Codes, and Appeal Forms

Answer Box: Getting Palynziq Covered in Virginia Blue Cross Blue Shield Virginia (Anthem) covers Palynziq for adults with PKU when blood phenylalanine levels remain ≥600 µmol/L despite dietary management. Prior authorization is required with strict criteria: age 18+, failed dietary therapy (±sapropterin), specialist involvement, and REMS enrollment. Fastest path

How to Get Tracleer (Bosentan) Covered by Cigna in Virginia: Prior Authorization Forms, Appeals, and REMS Requirements

Quick Answer: Getting Tracleer Covered by Cigna in Virginia Eligibility: Tracleer (bosentan) requires both Cigna prior authorization AND FDA REMS enrollment for pulmonary arterial hypertension (WHO Group 1). Fastest path: Have your cardiologist or pulmonologist submit PA documentation with right heart catheterization results while simultaneously enrolling in the Bosentan REMS

Renewing Qalsody (Tofersen) Approval with Cigna in Virginia: 2025 Guide to Documentation, Timelines, and Appeals

Answer Box: Renewing Your Qalsody (Tofersen) Coverage with Cigna Quick Summary: Cigna typically requires Qalsody (tofersen) renewal every 6 months for SOD1-ALS patients. Submit renewal documentation 2-4 weeks before your current authorization expires using CoverMyMeds or the EviCore portal. Required documents include updated ALSFRS-R scores, neurofilament light chain (NfL) levels,

How to Get HyperHEP (Hepatitis B Immune Globulin) Covered by Humana in Virginia: Prior Authorization Guide and Appeal Scripts

Answer Box: HyperHEP Coverage by Humana in Virginia HyperHEP (hepatitis B immune globulin) requires prior authorization from Humana and is typically non-formulary, but coverage is possible with proper documentation. You'll need detailed exposure documentation, proof of timing (within 7 days for needlestick, 14 days for sexual exposure), and

Getting Thiola/Thiola EC (Tiopronin) Covered by Humana in Virginia: Complete Coding, Appeals, and Documentation Guide

Answer Box: Getting Thiola/Thiola EC Covered by Humana in Virginia Eligibility: Humana covers Thiola/Thiola EC (tiopronin) for cystinuria with prior authorization. Fastest path: Submit PA with ICD-10 code E72.01, 24-hour urine cystine >500 mg/day, and specialist prescription. First step today: Gather lab results showing elevated

How to Get Voydeya (Danicopan) Covered by Humana in Virginia: Prior Authorization Guide with Appeals Process

Quick Answer: Getting Voydeya Covered by Humana in Virginia Voydeya (danicopan) requires prior authorization from Humana and is typically placed on Tier 5 (specialty) with ~33% coinsurance. The fastest path to approval: (1) Confirm your hematologist has documented PNH via flow cytometry and evidence of extravascular hemolysis despite C5 inhibitor

Aetna CVS Health Coverage for Givlaari (Givosiran) in Virginia: Medical Necessity Criteria and Appeals Guide

Quick Answer: Getting Givlaari (Givosiran) Covered by Aetna CVS Health in Virginia Aetna requires prior authorization for Givlaari through CVS Specialty Pharmacy. Key requirements: confirmed acute hepatic porphyria with elevated ALA/PBG levels, 4+ attacks per year or active symptoms requiring hospitalization/hemin, age 18+, and specialist prescriber. Submit via

Do You Qualify for Idelvion Coverage by Blue Cross Blue Shield in Virginia? Decision Tree & Appeal Guide

Answer Box: Idelvion (albutrepenonacog alfa) requires prior authorization from Blue Cross Blue Shield in Virginia for hemophilia B patients. You qualify if you have confirmed Factor IX deficiency (<40% activity), documented bleeding history, and have tried standard Factor IX products for 50+ exposure days. Start by having your hematologist