By Counterforce Health Team in Pemazyre (pemigatinib) —

Do You Qualify for Pemazyre (Pemigatinib) Coverage by Cigna in Washington? Decision Tree & Next Steps

Answer Box: Your Fastest Path to Pemazyre Coverage

Yes, you can get Pemazyre (pemigatinib) covered by Cigna in Washington if you have unresectable/metastatic cholangiocarcinoma with FGFR2 fusion/rearrangement and prior systemic therapy. The fastest path: 1) Confirm FGFR2 testing is complete, 2) Submit Cigna's prior authorization with all clinical documentation, 3) If denied, file internal appeal within 180 days—over 80% of appeals succeed with proper documentation. Washington residents have strong external review rights through the Office of Insurance Commissioner if needed.

Start today: Call Cigna at 1-800-244-6224 to request PA forms and verify your plan's specialty drug requirements.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible": Your Action Plan
  4. If "Possibly Eligible": Tests and Timeline
  5. If "Not Yet": Alternatives and Exceptions
  6. If Denied: Washington Appeal Process
  7. Visual Decision Flowchart
  8. Resources and Verification

How to Use This Decision Tree

This guide helps you navigate Cigna's coverage requirements for Pemazyre (pemigatinib) in Washington state. Start with the eligibility triage below, then follow the path that matches your situation. Each section includes specific documents, timelines, and contact information you'll need.

Important: Gather these items before starting:

  • Insurance card and member ID
  • Complete medical records and pathology reports
  • FGFR2 genetic testing results
  • Documentation of prior cancer treatments
  • Current prescription and provider information

Eligibility Triage: Do You Qualify?

Primary Requirements Checklist

✓ Diagnosis Confirmed?

  • Unresectable, locally advanced, or metastatic cholangiocarcinoma
  • Age 18 or older
  • Confirmed via pathology report with ICD-10 codes

✓ Required Genetic Testing?

  • FGFR2 fusion or rearrangement confirmed by NGS (Next-Generation Sequencing) or FISH testing
  • Lab report must specifically identify actionable FGFR2 alteration
  • Testing performed at approved laboratory

✓ Prior Therapy Documented?

  • At least one previous systemic therapy (typically gemcitabine + cisplatin)
  • Clear documentation of treatment dates, response, and progression
  • Medical records showing treatment failure or intolerance

✓ Clinical Requirements?

  • Ophthalmologic examination completed (required for monitoring)
  • No contraindications to FGFR inhibitor therapy
  • Adequate performance status for treatment
Requirement Status Next Step
All boxes checked ✓ Likely Eligible Proceed to Action Plan
Missing 1-2 items Possibly Eligible Complete missing requirements
Missing 3+ items Not Yet Review alternatives

If "Likely Eligible": Your Action Plan

Step-by-Step: Fastest Path to Approval

1. Contact Cigna Specialty Pharmacy (Patient/Caregiver)

  • Call 1-800-244-6224 for prior authorization forms
  • Verify Pemazyre is covered under your specific plan
  • Confirm if Express Scripts/Accredo handles specialty drugs
  • Timeline: Same day

2. Gather Clinical Documentation (Clinic Staff)

  • FGFR2 testing report with specific fusion/rearrangement details
  • Pathology report confirming cholangiocarcinoma diagnosis
  • Treatment history with dates and outcomes of prior therapies
  • Current imaging showing unresectable/metastatic disease
  • Timeline: 1-2 business days

3. Complete Prior Authorization (Prescribing Physician)

  • Submit via Cigna provider portal or fax
  • Include medical necessity letter addressing all coverage criteria
  • Attach all supporting documentation
  • Timeline: Same day submission

4. Baseline Eye Exam (Patient)

  • Schedule comprehensive ophthalmologic examination with OCT
  • Required before starting Pemazyre therapy
  • Document results for ongoing monitoring plan
  • Timeline: Within 1-2 weeks

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before dispensing Cigna provider portal Cigna PA Policy
Specialty Tier High-cost medication Member formulary Plan-specific formulary
FGFR2 Testing Molecular confirmation required Lab report FDA labeling requirements
Prior Therapy At least one systemic regimen Medical records Coverage policy criteria
Age Restriction 18 years or older Medical records FDA approval criteria

If "Possibly Eligible": Tests and Timeline

Missing FGFR2 Testing?

Next Steps:

  • Order NGS-based RNA fusion panel (preferred method)
  • Alternative: FISH testing if NGS unavailable
  • Ensure adequate tumor tissue sample
  • Timeline: 1-2 weeks for results

Testing Requirements:

  • Small biopsies are generally sufficient
  • Fresh or FFPE tissue acceptable
  • Liquid biopsy under investigation but not standard
  • Lab must identify specific FGFR2 fusion partner

Missing Prior Therapy Documentation?

What to Track:

  • Exact regimen names and dates
  • Response assessment (imaging, tumor markers)
  • Reason for discontinuation (progression, toxicity)
  • Any treatment breaks or modifications

Timeline to Re-apply:

  • Gather records: 3-5 business days
  • Resubmit PA: Same day
  • Decision timeline: 72 hours to 14 days

If "Not Yet": Alternatives and Exceptions

Alternative Treatment Options

For FGFR2+ Cholangiocarcinoma:

  • Futibatinib (Lytgobi) - newer FGFR2 inhibitor
  • Standard chemotherapy regimens
  • Clinical trial enrollment

For Non-FGFR2 Cases:

  • Gemcitabine + cisplatin (first-line standard)
  • Targeted therapies based on other molecular markers
  • Immunotherapy combinations (select cases)

Exception Request Process

Medical Necessity Exception:

  • Submit detailed letter explaining unique clinical circumstances
  • Include peer-reviewed literature supporting off-label use
  • Provide evidence of failed standard alternatives
  • Timeline: 30-60 days for review

Formulary Exception:

If Denied: Washington Appeal Process

Internal Appeals with Cigna

First-Level Internal Appeal:

  • Timeline: Must file within 180 days of denial
  • Method: Written request to Cigna appeals department
  • Required documents: Denial letter, medical records, physician letter
  • Decision timeline: 30 days (72 hours if expedited)
  • Contact: 1-800-244-6224

Second-Level Internal Appeal:

  • Available if first appeal denied
  • Same documentation requirements
  • Independent medical reviewer
  • Timeline: 30 days for decision

Peer-to-Peer Review

When to Request:

  • Complex cases requiring clinical discussion
  • Available during initial PA or first appeal
  • Prescribing physician speaks directly with Cigna medical director

How to Arrange:

  • Request through Cigna provider services
  • Prepare clinical rationale and supporting evidence
  • Success rate: High for well-documented cases

External Review in Washington

Washington State Independent Review:

  • Available after exhausting internal appeals
  • Contact: Washington Office of Insurance Commissioner
  • Phone: 1-800-562-6900
  • Timeline: 180 days from final internal denial to request
  • Decision: Binding on Cigna if approved

Required Documentation:

  • All denial letters from Cigna
  • Complete medical records
  • Physician support letter
  • FGFR2 testing results
From Our Advocates: In our experience helping Washington patients with specialty drug appeals, success rates exceed 80% when appeals include comprehensive molecular testing results, detailed treatment history, and a strong medical necessity letter. The key is demonstrating that Pemazyre specifically addresses the patient's FGFR2 alteration when standard therapies have failed.

Visual Decision Flowchart

Start → Cholangiocarcinoma Diagnosis?
    ↓ Yes
FGFR2 Testing Done?
    ↓ Yes → FGFR2 Fusion/Rearrangement Found?
        ↓ Yes → Prior Systemic Therapy?
            ↓ Yes → Submit PA → Approved?
                ↓ No → Internal Appeal → External Review
    ↓ No (at any step) → Complete Requirements → Return to Previous Step

Common Denial Reasons & Fixes

Denial Reason How to Overturn Required Documents
No FGFR2 testing Submit molecular testing report NGS or FISH lab results
Insufficient prior therapy Document treatment history Medical records, imaging
Off-label use Medical necessity exception Literature review, guidelines
Missing eye exam Complete ophthalmologic evaluation OCT results, monitoring plan
Quantity limits Clinical justification letter Dosing rationale, safety data

Costs & Savings Options

Manufacturer Support:

  • Incyte Cares Program
  • Copay assistance for eligible patients
  • Patient assistance program for uninsured/underinsured

State Programs:

  • Washington Apple Health (Medicaid expansion)
  • Prescription drug assistance programs
  • Cancer care grants through local foundations

Clinician Corner: Medical Necessity Letter

Essential Elements to Include:

  • Specific FGFR2 fusion/rearrangement details
  • Complete prior treatment history with outcomes
  • Clinical rationale for Pemazyre over alternatives
  • Monitoring plan including ophthalmologic surveillance
  • Expected treatment duration and goals

Key References:

FAQ

Q: How long does Cigna prior authorization take in Washington? A: Standard PA decisions: 72 hours to 14 days. Expedited reviews for urgent cases: 24-72 hours.

Q: What if Pemazyre is non-formulary on my plan? A: Request a formulary exception with medical necessity documentation. Success rates are high for FDA-approved indications with proper clinical support.

Q: Can I request an expedited appeal? A: Yes, if delay would seriously jeopardize your health. Contact Cigna immediately and request expedited review with physician support.

Q: Does step therapy apply if I've had prior treatments outside Washington? A: No, documented prior systemic therapy from any location satisfies step therapy requirements.

Q: What happens if my FGFR2 test is negative? A: Pemazyre won't be covered for cholangiocarcinoma without FGFR2 alterations. Discuss alternative targeted therapies or standard chemotherapy with your oncologist.

Q: How much does Pemazyre cost without insurance? A: Specialty pricing typically ranges in the high four- to five-figure monthly range. Manufacturer assistance programs may significantly reduce costs.

When to Escalate

Contact Washington Insurance Commissioner if:

  • Cigna doesn't respond within required timeframes
  • You believe the denial violates Washington insurance law
  • You need help navigating the external review process
  • You suspect discriminatory coverage practices

Contact Information:

Resources and Verification

Official Cigna Resources:

Washington State Resources:

Clinical Resources:

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters, identifies coverage gaps, and creates evidence-backed appeals tailored to each payer's specific requirements—helping you get the medications you need faster and with less administrative burden.

This guide is for informational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance plan for the most current coverage criteria and clinical recommendations. Coverage policies may change, and individual circumstances vary.

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