By Counterforce Health Team in Gattex (teduglutide) —

Do You Qualify for Gattex (Teduglutide) Coverage by Cigna in Texas? Decision Tree & Next Steps

Answer Box: Getting Gattex (Teduglutide) Covered by Cigna in Texas

Quick Path to Approval: Cigna requires prior authorization for Gattex with strict criteria: confirmed short bowel syndrome, ≥12 months parenteral nutrition dependence (≥3 days/week with documented logs), gastroenterologist prescription, recent colonoscopy, and weight-based dosing. Submit via Cigna PA form to Express Scripts/Accredo. If denied, appeal within 180 days internally, then request Texas external review through an Independent Review Organization (IRO) if medical necessity is disputed.

First step today: Gather 12 months of parenteral nutrition logs showing days/week and volumes, then contact your gastroenterologist to complete the Cigna Gattex PA form.

Table of Contents

How to Use This Decision Tree

This guide helps you determine if you qualify for Gattex (teduglutide) coverage through Cigna in Texas and provides specific next steps based on your situation. Gattex is a GLP-2 analog that can reduce parenteral nutrition needs in patients with short bowel syndrome, but it requires extensive documentation for insurance approval.

Before you start: Have your insurance card, recent medical records, and parenteral nutrition logs readily available. This process typically takes 2-4 weeks from initial submission to coverage determination.

Eligibility Triage: Do You Qualify?

✅ Likely Eligible if you have:

  • Confirmed short bowel syndrome diagnosis with surgical records
  • Age ≥1 year and weight ≥10 kg
  • Parenteral nutrition dependence ≥12 months, ≥3 days per week
  • Detailed PN logs showing volumes and frequency
  • Gastroenterologist or SBS specialist involved in care
  • Recent colonoscopy (within 6 months) with polyps removed if present
  • No active GI malignancy, intestinal obstruction, or severe liver disease

⚠️ Possibly Eligible if you have:

  • Short bowel syndrome but PN dependence <12 months
  • Incomplete parenteral nutrition documentation
  • No recent colonoscopy or GI specialist involvement
  • Enteral nutrition trials not yet optimized
  • Some but not all required lab work completed

❌ Not Yet Eligible if you have:

  • No confirmed short bowel syndrome diagnosis
  • No parenteral nutrition dependence or <3 days per week
  • Active GI malignancy or untreated intestinal obstruction
  • Child-Pugh C liver disease
  • Age <1 year or insufficient weight for dosing

If "Likely Eligible": Document Checklist

Required Documentation for Cigna PA Submission

Patient Information

  • Cigna member ID and insurance card copy
  • Patient demographics (name, DOB, address, phone)
  • Current weight for dose calculation (0.05 mg/kg/day)

Clinical Documentation

  • Short bowel syndrome diagnosis with ICD-10 code
  • Surgical reports showing bowel resection details
  • 12+ months of parenteral nutrition logs (days/week, volumes, calories)
  • Gastroenterologist consultation note recommending Gattex
  • Recent colonoscopy report (within 6 months) with pathology if applicable
  • Current labs: CBC, comprehensive metabolic panel, liver function tests

Prescription Details

  • Gattex 5mg prescription with weight-based dosing
  • Duration of therapy request (typically 6-12 months initial)
  • Preferred specialty pharmacy: Accredo (NCPDP 4436920)

Submission Path

  1. Complete Cigna Gattex PA form
  2. Fax to (855) 840-1678 or submit via CoverMyMeds/SureScripts
  3. For urgent requests, call 800-882-4462 and mark "EXPEDITED"
  4. Standard review: 5 business days; expedited: 72 hours

If "Possibly Eligible": Tests to Request

Missing Documentation to Obtain

If PN dependence <12 months:

  • Continue current PN regimen and maintain detailed logs
  • Document all enteral nutrition optimization attempts
  • Track complications from PN (infections, liver issues, access problems)
  • Plan to resubmit after reaching 12-month threshold

If missing specialist involvement:

  • Request gastroenterology or SBS specialist consultation
  • Ensure specialist note includes:
    • SBS diagnosis confirmation
    • Assessment of remaining bowel length
    • Failed conservative therapy documentation
    • Specific rationale for Gattex therapy
    • Goals for parenteral nutrition reduction

If colonoscopy not recent:

  • Schedule colonoscopy within 6 months of PA submission
  • Ensure any polyps are removed before starting Gattex
  • Obtain complete procedure and pathology reports

Timeline to Re-apply

Most patients need 3-6 months to complete missing requirements. Use this time to optimize enteral nutrition and gather comprehensive documentation.

If "Not Yet Eligible": Alternatives to Discuss

Conservative Management Options

  • Enteral nutrition optimization: Work with dietitian on polymeric formulas, continuous feeds, oral rehydration solutions
  • Medication management: Antidiarrheals (loperamide, diphenoxylate), proton pump inhibitors, octreotide for high-output states
  • Surgical evaluation: Consider intestinal lengthening procedures or transplant evaluation if appropriate

Preparing for Exception Requests

Even if standard criteria aren't met, you may qualify for a formulary exception if:

  • Severe PN-related complications (recurrent line infections, liver disease)
  • Rapid clinical deterioration despite optimal conservative care
  • Contraindications to standard SBS management approaches

Document these circumstances thoroughly and request peer-to-peer review with Cigna's medical director.

If Denied: Appeal Path Chooser

Level 1: Internal Appeal (Required First Step)

  • Deadline: 180 days from denial date
  • Submission: Cigna member portal, phone (1-800-88CIGNA), or fax (1-866-873-8279)
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Include: Denial letter, medical necessity letter, updated clinical records, peer-reviewed evidence

Level 2: Peer-to-Peer Review

  • When to request: If denial cites "not medically necessary"
  • Process: Your gastroenterologist calls 1-800-88CIGNA within 180 days
  • Outcome: Response within 5 business days
  • Tip: Have prescriber reference FDA labeling and clinical trial data showing PN reduction

Level 3: Texas External Review (IRO)

  • Eligibility: After internal appeal denial for medical necessity disputes
  • Deadline: 4 months from final internal denial
  • Process: Contact Texas Department of Insurance at 1-800-252-3439
  • Timeline: 20 days standard, 72 hours expedited, 5 days urgent
  • Cost: Free (Cigna pays for review)
  • Success rate: Approximately 50-70% overturn rate for well-documented cases
From our advocates: We've seen cases where initial Gattex denials were overturned at the IRO level when families provided comprehensive PN logs showing clear dependence and documented failed conservative therapy. The key was demonstrating that standard treatments had been optimized over many months before requesting Gattex.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Gattex prescriptions Cigna formulary, PA form Cigna PA Form
Formulary Tier Specialty tier with PA Texas 2024 PDL Cigna Texas PDL
Age Requirement ≥1 year old, ≥10 kg weight FDA labeling criteria Cigna Policy #375
PN Dependence ≥12 months, ≥3 days/week Clinical documentation Cigna Policy #375
Specialist Requirement Gastroenterologist prescription/consult PA form attestation Cigna PA Form
Specialty Pharmacy Accredo preferred Dispensing requirements Cigna PA Form
Appeal Deadline 180 days from denial Texas insurance law Cigna Appeals

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
Insufficient PN documentation Submit detailed 12-month PN logs Volume, frequency, calories, dates
Missing specialist involvement Obtain GI consultation Specialist note with SBS diagnosis and Gattex rationale
No recent colonoscopy Schedule and complete procedure Colonoscopy report with pathology if applicable
Incorrect dosing Verify weight-based calculation Current weight, 0.05 mg/kg/day calculation
Wrong specialty pharmacy Redirect prescription Send to Accredo (NCPDP 4436920)
Non-formulary status Request formulary exception Medical necessity letter citing no alternatives
Medical necessity questioned Request peer-to-peer review Clinical guidelines, trial data, patient-specific rationale

FAQ: Cigna Gattex Coverage in Texas

How long does Cigna prior authorization take in Texas? Standard PA review takes 5 business days. Expedited reviews (for urgent cases) are completed within 72 hours. Call 800-882-4462 for urgent requests.

What if Gattex is non-formulary on my Cigna plan? Request a formulary exception by demonstrating medical necessity and lack of therapeutic alternatives. Include documentation of failed conservative therapy and PN-related complications.

Can I request an expedited appeal in Texas? Yes, if delay would seriously jeopardize your health. Mark appeals "EXPEDITED" and include physician statement of urgency. Timeline reduces to 72 hours for internal review.

Does Cigna require step therapy for Gattex? Yes, you must document failed or inadequate response to enteral nutrition optimization, antidiarrheals, and other conservative SBS management before Gattex approval.

What specialty pharmacy does Cigna require for Gattex? Accredo is the preferred specialty pharmacy (NCPDP 4436920, fax 888-302-1028, phone 866-759-1557). Alternative pharmacies may be approved with network exceptions.

How much does Gattex cost with Cigna coverage? Costs vary by plan. Gattex is typically a high-tier specialty drug with significant copays. Takeda offers copay assistance that may reduce costs to $0 for eligible patients with commercial insurance.

Can I appeal to Texas state regulators if Cigna denies coverage? Yes, after exhausting internal appeals, you can request external review through a Texas Independent Review Organization (IRO). Contact Texas Department of Insurance at 1-800-252-3439.

What happens if my appeal is successful? If an internal appeal or IRO review overturns the denial, Cigna must authorize coverage and may need to provide retroactive coverage for the period during appeal.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals for complex specialty medications like Gattex. Our platform analyzes denial letters, identifies specific coverage criteria, and drafts evidence-backed appeals that address each payer's requirements point-by-point. We help patients, clinicians, and specialty pharmacies navigate the prior authorization process with targeted documentation that significantly improves approval rates.

For Gattex appeals, Counterforce Health can help gather the right clinical evidence—from FDA labeling to parenteral nutrition logs—and structure appeals that meet Cigna's specific requirements while tracking Texas appeal deadlines and procedural requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage criteria and appeal processes may change. Always verify current requirements with your specific Cigna plan and consult healthcare providers for medical decisions. For assistance with Texas insurance appeals, contact the Texas Department of Insurance at 1-800-252-3439.

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