By Counterforce Health Team in Berinert (C1-esterase inhibitor, IV) —

Get Berinert (C1-Esterase Inhibitor) Covered by Cigna in Ohio: Complete Prior Authorization & Appeals Guide

Answer Box: Getting Berinert Covered by Cigna in Ohio

Yes, Cigna covers Berinert for hereditary angioedema (HAE) attacks, but requires prior authorization. Your allergist/immunologist must submit documentation proving HAE diagnosis (low C1-INH and C4 levels), attack history, and dosing needs. Standard approval takes 5 business days; expedited reviews complete in 24 hours for urgent cases. If denied, Ohio residents can file internal appeals (180 days) followed by external review through the Ohio Department of Insurance within 180 days of final denial. Start by having your doctor submit the Cigna PA form with complete HAE lab results.

Table of Contents

Is Berinert Covered by Cigna?

Cigna covers Berinert (IV C1-esterase inhibitor) for treating acute HAE attacks in patients with confirmed hereditary angioedema. The medication is typically managed through Cigna's specialty pharmacy network, including Express Scripts/Accredo, and requires prior authorization for all members.

Coverage applies to:

  • Acute abdominal, facial, or laryngeal HAE attacks
  • On-demand treatment (not routine prophylaxis)
  • Patients with documented HAE Type I or II
Note: Berinert is FDA-approved specifically for acute treatment, not prevention. For prophylactic HAE therapy, Cigna covers alternatives like Haegarda or Cinryze under separate policies.

Prior Authorization Requirements

Coverage at a Glance

Requirement Details Documentation Needed Source
Prior Authorization Required for all members Completed PA form Cigna PA Forms
HAE Diagnosis Types I or II confirmed Lab results showing low C1-INH Coverage Policy
Specialist Prescription Required Allergist/immunologist order Coverage Policy
Quantity Limits 4 doses per month max Attack documentation Policy varies by plan
Step Therapy Not required None Coverage Policy

Submission Process & Timeline

Step-by-Step: Fastest Path to Approval

  1. Gather Required Documents (Patient/Clinic)
    • Insurance card and member ID
    • Complete HAE lab results (C1-INH, C4, C1q levels)
    • Attack history and emergency room records
    • Current weight for dosing calculations
  2. Complete Prior Authorization Form (Prescriber)
    • Download from Cigna PA forms page
    • Include all required clinical documentation
    • Calculate dose: 20 IU/kg body weight per attack
  3. Submit Request (Prescriber)
    • Cigna provider portal (preferred)
    • Fax to (855) 840-1678
    • CoverMyMeds online portal
    • SureScripts through EHR
  4. Track Status (Patient/Clinic)
    • Standard review: 5 business days
    • Expedited review: 24 hours (for urgent cases)
    • Call (800) 882-4462 for status updates
  5. Receive Decision (All parties notified)
    • Approval: Authorization processed in pharmacy system
    • Denial: Written explanation with appeal rights provided
Tip: For laryngeal attacks or urgent needs, request expedited review when submitting. Include physician certification that delay would seriously jeopardize health.

Coverage Criteria & Documentation

Medical Necessity Requirements

Cigna approves Berinert when documentation shows:

Diagnostic Confirmation:

  • HAE Type I or II diagnosis with genetic testing or family history
  • C1-INH functional levels below laboratory normal range
  • C4 levels below 50% of normal at baseline
  • Normal C1q levels (to exclude acquired angioedema)

Clinical Justification:

  • Documented history of acute HAE attacks
  • Attack severity requiring medical intervention
  • Patient weight for proper dosing (20 IU/kg per attack)
  • Plan for emergency use and administration training

Clinician Corner: Medical Necessity Letter Checklist

When writing the medical necessity letter, include:

✓ Patient History: HAE diagnosis date, genetic testing results, family history ✓ Attack Pattern: Frequency, severity, locations (abdominal, facial, laryngeal)
✓ Prior Treatments: Previous HAE medications tried and outcomes ✓ Clinical Rationale: Why Berinert is appropriate for this patient's attack profile ✓ Dosing Plan: Weight-based calculation (20 IU/kg), maximum 2 doses per 24 hours ✓ Safety Monitoring: Plan for administration, emergency backup for laryngeal attacks ✓ Guidelines: Reference FDA labeling and HAE treatment guidelines

Costs & Patient Support

Typical Coverage Structure:

  • Specialty tier copay or coinsurance applies
  • Prior authorization required regardless of tier
  • Buy-and-bill pricing varies by site of care

Patient Assistance Options:

  • CSL Behring Patient Support Program - copay assistance and prior authorization support
  • Chronic Disease Fund and other patient foundations
  • Accredo specialty pharmacy financial counseling
Important: Verify your specific copay through Cigna member services, as costs vary significantly between individual and employer plans.

Common Denial Reasons & Solutions

Denial Reason How to Fix Required Documents
Incomplete HAE diagnosis Submit complete lab panel C1-INH functional, C4, C1q levels with reference ranges
Missing specialist involvement Get allergist/immunologist consultation Specialist evaluation and prescription
Prophylactic use requested Clarify acute treatment indication Attack diary, emergency room records
Quantity limit exceeded Document attack frequency Medical records showing attack pattern
Site of care restriction Request exception or change location Medical necessity for home/office administration

Scripts for Common Situations

Patient Script for Cigna Customer Service: "I'm calling about prior authorization status for Berinert for hereditary angioedema. My member ID is [ID number]. My doctor submitted the request on [date]. Can you tell me the current status and if any additional information is needed?"

Clinic Script for Peer-to-Peer Review: "I'm requesting a peer-to-peer review for Berinert denial. My patient has confirmed HAE Type I with documented C1-INH deficiency and recurrent acute attacks requiring emergency treatment. The requested dose of 20 IU/kg follows FDA labeling for acute attack management."

Appeals Process in Ohio

Internal Appeals with Cigna

Timeline: File within 180 days of denial notice Process:

  1. Submit written appeal with medical records
  2. Include physician letter addressing denial reasons
  3. Standard decision within 15 business days
  4. Expedited decision within 24 hours if urgent

Required Documents:

  • Original denial letter
  • Complete medical records supporting HAE diagnosis
  • Updated attack history and emergency visits
  • Physician statement of medical necessity

Ohio External Review Process

If Cigna upholds the denial, Ohio residents can request external review through the Ohio Department of Insurance.

Key Details:

  • Deadline: 180 days from final internal denial
  • Process: Independent medical experts review case
  • Timeline: 30 days standard, 72 hours expedited
  • Cost: Free to consumers
  • Decision: Binding on Cigna if overturned

Contact Information:

  • Ohio Department of Insurance Consumer Services: 1-800-686-1526
  • Website: insurance.ohio.gov
  • External Review Request Form available online
Ohio Advantage: Even if Cigna claims your case isn't eligible for external review, the Ohio Department of Insurance can independently determine eligibility and order a review.

Renewal Requirements

Berinert authorizations are typically approved for 12 months. For renewal, your doctor must document:

  • Continued HAE diagnosis and attack pattern
  • Favorable clinical response to treatment
  • Updated weight for dosing adjustments
  • Any changes in attack frequency or severity
  • Continued medical necessity for acute treatment

Renewal Timeline: Submit 30-60 days before expiration to avoid gaps in coverage.

Specialty Pharmacy Details

Cigna typically requires Berinert to be dispensed through specialty pharmacy networks:

Primary Options:

  • Accredo Specialty Pharmacy (Cigna's preferred vendor)
  • Express Scripts specialty division
  • Select hospital outpatient pharmacies

Why Specialty Pharmacy:

  • Cold chain storage requirements
  • Prior authorization coordination
  • Patient education and training
  • Insurance billing expertise

Patient Responsibilities:

  • Coordinate delivery timing with attack patterns
  • Maintain proper refrigeration (36-46°F)
  • Complete administration training if self-treating
  • Have emergency plan for laryngeal attacks

Troubleshooting Common Issues

Portal Access Problems:

  • Reset password through Cigna member portal
  • Contact customer service at number on ID card
  • Use provider portal if you're clinic staff

Missing Prior Authorization Forms:

  • Download current forms from Cigna PA forms page
  • Verify you're using the correct form for C1-esterase inhibitors
  • Contact Cigna provider services for assistance

Delayed Approvals:

  • Call (800) 882-4462 for status updates
  • Request expedited review for urgent cases
  • Ensure all required documentation was submitted

Pharmacy Transfer Issues:

  • Confirm specialty pharmacy requirements with Cigna
  • Provide complete prescription and PA approval
  • Allow 24-48 hours for system updates

Frequently Asked Questions

How long does Cigna prior authorization take for Berinert in Ohio? Standard review takes 5 business days after Cigna receives complete documentation. Expedited review for urgent cases is completed within 24 hours.

What if Berinert is non-formulary on my Cigna plan? You can request a formulary exception through your physician. The process takes 2 business days for standard review, 24 hours for expedited requests when medically urgent.

Can I request an expedited appeal in Ohio? Yes, if delay would seriously jeopardize your health or ability to regain function. Both internal Cigna appeals and Ohio external reviews offer expedited timelines.

Does step therapy apply if I've used HAE medications outside Ohio? No, Cigna's policy explicitly states that patients should not be required to fail alternative therapies as a prerequisite for C1-esterase inhibitor approval.

What's the maximum dose Cigna will approve per attack? Cigna follows FDA labeling: 20 IU/kg body weight per attack, with maximum 2 doses within 24 hours. Monthly limits are typically 4 doses total.

Who can prescribe Berinert for Cigna coverage? The prescription must be written by or in consultation with an allergist/immunologist or HAE specialist. Primary care physicians typically cannot obtain approval without specialist involvement.

What happens if I need Berinert while traveling in Ohio? Contact your specialty pharmacy for travel supplies or emergency pharmacy options. Keep your PA approval documentation and emergency action plan with you.

How do I find HAE specialists in Ohio for Cigna approval? The Hereditary Angioedema Association maintains a physician directory. Major Ohio medical centers like Cleveland Clinic and Ohio State often have HAE specialists.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed responses. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals that align with payer requirements, pulling the right clinical evidence and procedural details to support HAE medication approvals.

When dealing with complex prior authorizations like Berinert, having expert support can make the difference between approval and denial. Counterforce Health streamlines this process by ensuring your appeal addresses the specific criteria Cigna uses for HAE medication coverage decisions.

Sources & Further Reading

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions and treatment recommendations. Coverage policies and requirements may vary by plan and change over time.

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