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--- prior_auths [2025/04/02 14:27] – 73.123.100.169
+++ prior_auths [2025/10/30 19:50] (current) – 73.123.100.169
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+Medicaid based plans (MGB ACO, Wellsense, MassHealth) do not seem to cover patanase nasal spray.
-Some insurances have been denying Dupixent and Xolair PA's for silly reasons recently. Not sure if this helps, but here are some general guidelines of information insurance companies are looking for in physician documentation in order to approve the medications.
+In office admin through buy & bill- Healix completes PA (buy & bill is required by Medicare but no PA required if medical criteria is met)
+Medications obtained through pharmacy benefits- KK2 completes PA (CoverMyMeds, PromptPA, MBG/ Optum portal, paper forms)
-DUPIXENT (raised EOS count required for all)
+Commercial insurances (MGB, BCBS, HP, etc.) require PA's for all biologics and specialty medications. Most are now covering Neffy.
-. Atopic derm (L20.9 or L20.89)
--6 months or older with diagnosis of moderate-to-severe atopic dermatitis
--documentation of disease burden (SCORAD, BSA %, EASI, etc)
--inadequate response to topical corticosteroids and topical calcineurin inhibitors
--inadequate response to oral systemic immunosuppressants or corticosteroids
-. Nasal Polyps (J33.9 or J33.0)
--18 years or older with diagnosis of polyps supported by rhinoscopy, endoscopy or CT scan
--inadequate response to intranasal and systemic corticosteroids
--history of sino-nasal surgery
-*Depending on insurance, some PA's will ask if med is being prescribed with referral from/ in consultation with ENT provider*
-. Asthma (J45.40 or J45.50)
--6 years or older with diagnosis of moderate-to-severe eosinophilic or oral corticosteroid dependent asthma
--documentation of 3 months of patient trying asthma treatments
--documentation of frequency of hospitalizations, exacerbations, use of rescue therapy
-. EoE (K20.0)
--1 year or older & weighs over 15kg
--diagnosis of EoE as supported by esophageal biopsy with >15 EOS/HPF
--documentation of inadequate response to at least 8 weeks of high dose PPI and 6-8 weeks of oral swallowed steroids like budesonide or fluticasone propionate
-XOLAIR (raised pretreatment total IgE required for all)
-. CIU (L50.1 or L50.8) - insurances don't like L50.9
--documentation of at least trial and failure of up-dosed H1 and H2 histamine blockers
-*Some insurances asking for affected BSA %
-. Moderate-to-severe asthma (J50.40, J50.50)
--history of positive skin or RAST test to perennial aeroallergen
--documentation of symptoms being inadequately controlled with ICS
-. Nasal polyps (J33.9, J33.0, J33.8)
--documentation of inadequate response to nasal corticosteroids
-. IgE mediated food allergy (Z91.010, Z91.011, Z91.012,  Z91.013)
--Clinical history consistent with IgE-mediated food allergy
--Positive IgE and/or positive skin prick test and/or Oral Food Challenge to allergenic food(s)
--Pretreatment serum IgE level IU/mL
 The in office sales reps and reimbursement managers do not speak with patients directly. All of the reps have just advised patients reach out to the companies through their customer support lines for any financial questions.
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 Fasenra: 1-833-360-HELP(4357)
-The only direct contact for patient help that I have is for Dupixent (contact info per Jesse):
+Direct contact for patient help for Dupixent:
-Vanessa Saesee, Dupixent MyWay Case Manager
+Char Williams, Territory Case Manager, Sonexus™ Access and Patient Support
-Office: 1-844-DUPIXENT (1-844-387-4936) ext. 15764
+S. Edmonds Lane, Suite 300 | Lewisville, TX  75067
+.844.387.4936 ext. 60656
+Optum- direct # for providers: 855-215-0235
+Optum Specialty contact:
+Alex- 224-231-1657
-Optum- direct # for providers: 855-215-0235