Topic

Washington

A collection of 233 issues

Myths vs. Facts: Getting iLink® Corneal Cross-Linking Covered by Humana in Washington

Answer Box: Fast Facts for Washington Residents Myth-busting reality: Humana covers FDA-approved iLink® corneal cross-linking for progressive keratoconus when strict medical necessity criteria are met. Over 95% of commercial plans cover this procedure, but prior authorization is required. Success depends on documented disease progression, proper clinical records, and using only

If Krystexxa (Pegloticase) Isn't Approved by Humana in Washington: Formulary Alternatives & Exception Paths

Answer Box: Humana Alternatives to Krystexxa in Washington If Humana denies Krystexxa (pegloticase), you must first try formulary alternatives—allopurinol, febuxostat, and typically probenecid—for at least 3 months each at maximum tolerated doses. Document treatment failures with serum uric acid levels >6 mg/dL, then request a formulary

Myths vs. Facts: Getting Gamifant (Emapalumab) Covered by Humana in Washington

Quick Answer: Gamifant Coverage by Humana in Washington Fact: Humana Medicare Advantage requires prior authorization for Gamifant (emapalumab) with strict HLH diagnostic criteria and conventional therapy failure documentation. Fastest path: Submit PA with HLH-2004 criteria proof, genetic testing results, and detailed records of failed etoposide/steroid therapy. First step today:

Requirements Checklist to Get Brineura (cerliponase alfa) Covered by Aetna (CVS Health) in Washington

Answer Box: Getting Started Aetna (CVS Health) requires prior authorization for Brineura (cerliponase alfa) with strict clinical criteria. Your fastest path to approval: confirm CLN2 diagnosis with genetic/enzyme testing, ensure treatment by a metabolic specialist at an approved infusion center, and submit complete documentation showing motor function assessment. Start

How to Get Strimvelis Gene Therapy Covered by UnitedHealthcare in Washington: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Strimvelis Covered by UnitedHealthcare in Washington Strimvelis gene therapy for ADA-SCID requires prior authorization from UnitedHealthcare through OptumRx, with extensive documentation of genetic diagnosis (ICD-10 D81.31), failed standard therapies, and specialist support. Since Strimvelis isn't FDA-approved and is only available in Milan, Italy, you&

If Ibrance Isn't Approved by Blue Cross Blue Shield in Washington: Formulary Alternatives & Exception Paths

Answer Box: Your Options When Ibrance Is Denied If Blue Cross Blue Shield denies Ibrance (palbociclib) in Washington, you have three main paths: request formulary alternatives like Kisqali (ribociclib) or Verzenio (abemaciclib), file a formulary exception with clinical justification, or appeal the denial through Washington's robust external review

How to Get Cimzia Covered by Blue Cross Blue Shield in Washington: Prior Auth, Appeals, and Cost-Saving Strategies

Quick Answer: Getting Cimzia Covered by Blue Cross Blue Shield in Washington Cimzia (certolizumab pegol) requires prior authorization from Blue Cross Blue Shield plans in Washington and is typically placed on specialty tier formularies. To get approved: (1) Have your provider submit a PA request with diagnosis documentation and prior

Get Xospata (Gilteritinib) Approved by Cigna in Washington: Prior Authorization, Appeals & Alternatives

Answer Box: Getting Xospata (Gilteritinib) Covered by Cigna in Washington Eligibility: Xospata requires prior authorization from Cigna for adults with relapsed/refractory AML who have FLT3-mutated disease confirmed by an FDA-approved test. Fastest path: Have your hematologist submit clinical documentation showing FLT3 mutation positivity, prior therapy failures, and medical necessity

Aetna's Coverage Criteria for Vyndaqel/Vyndamax (Tafamidis) in Washington: Complete Prior Authorization Guide

Answer Box: Getting Vyndaqel/Vyndamax Covered by Aetna in Washington To get tafamidis covered by Aetna in Washington, you need: confirmed ATTR-CM diagnosis via PYP scan (grade 2-3) with AL amyloidosis exclusion, NYHA class I-III heart failure, and cardiology oversight. First step: Have your cardiologist submit prior authorization with complete

Getting Pyrukynd (Mitapivat) Covered by UnitedHealthcare in Washington: Complete Prior Authorization and Appeals Guide

Quick Answer: Your Path to Pyrukynd Coverage UnitedHealthcare requires strict prior authorization for Pyrukynd (mitapivat) in Washington. You'll need genetic confirmation of pyruvate kinase deficiency (≥2 PKLR variants, ≥1 missense), baseline hemoglobin ≤10 g/dL, limited transfusion history, and hematologist oversight. If denied, Washington's external review