By Counterforce Health Team in Darzalex / Darzalex Faspro (daratumumab) —

Get Darzalex Covered by Cigna in Illinois: Complete Prior Authorization and Appeal Guide

Answer Box: Getting Darzalex Covered by Cigna in Illinois

Cigna requires prior authorization for both Darzalex IV and Darzalex Faspro (subcutaneous) under most commercial plans in Illinois. Submit the official PA form via CoverMyMeds or fax to (855) 840-1678. Standard approval takes 5 business days; expedited reviews process in 72 hours for urgent cases. If denied, you have 180 days for internal appeals, then 30 days for Illinois external review through the Department of Insurance.

First step today: Have your oncologist gather your multiple myeloma diagnosis (ICD-10), prior therapy records, and submit via the Cigna provider portal or CoverMyMeds.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Forms and Submission Portals
  4. Common Denial Reasons and How to Fix Them
  5. Appeals Process for Illinois Residents
  6. Contact Numbers and Support
  7. Cost Savings and Patient Assistance
  8. FAQ

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for both IV and subcutaneous forms Cigna PA form
Formulary Tier Specialty tier (20-40% coinsurance) Check via Cigna member portal
Step Therapy May require trying other MM treatments first Plan-specific; verify in portal
Site of Care Must use lowest-cost appropriate setting Oncologist office or infusion center
Specialty Pharmacy Dispensed through Accredo/Express Scripts Automatic enrollment after PA approval

Step-by-Step: Fastest Path to Approval

1. Verify Your Coverage (Patient + Clinic)

Log into your Cigna member portal or call the number on your ID card. Confirm Darzalex is on your plan's formulary and check if step therapy applies to your specific plan.

2. Gather Required Documentation (Oncologist)

Your doctor needs:

  • Multiple myeloma diagnosis with ICD-10 code
  • Complete prior therapy history (what you tried, how long, why it failed)
  • Current lab values and performance status
  • Weight in kg for dosing calculations
  • Planned combination therapy details

3. Submit Prior Authorization (Oncologist)

Fastest method: Use CoverMyMeds portal for electronic submission.

Alternative methods:

  • Cigna provider portal at CignaforHCP.com
  • Fax to (855) 840-1678
  • For urgent cases, call (800) 882-4462

4. Track Your Request

Standard processing: 5 business days. Check status via the provider portal or call Cigna provider services.

5. If Approved: Specialty Pharmacy Setup

Cigna will automatically enroll you with Accredo for specialty drug dispensing. Expect a call within 3-5 days to coordinate delivery and infusion scheduling.

6. If Denied: Request Peer-to-Peer Review

Your oncologist can request a phone consultation with a Cigna medical director within 72 hours of denial. This often resolves coverage issues faster than formal appeals.

Forms and Submission Portals

Primary Submission Methods

Electronic (Preferred):

Fax Submissions:

  • Standard PA requests: (855) 840-1678
  • Urgent requests: Call (800) 882-4462 first, then fax

Key Form Requirements

The official Darzalex PA form requires:

  • Complete patient demographics and Cigna ID
  • Prescriber NPI, DEA, and specialty certification
  • Specific combination therapy selection (e.g., with lenalidomide + dexamethasone)
  • Prior therapy documentation with dates and outcomes
  • Infusion site details and tax ID
Tip: Mark "urgent" if treatment delay would jeopardize your health. Include a brief clinical justification for expedited review.

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn
Insufficient prior therapy Submit detailed records of failed treatments with dates, doses, and discontinuation reasons
Missing combination details Specify exact regimen (e.g., Darzalex + Revlimid + dexamethasone) with NCCN guideline reference
Site of care issues Provide facility accreditation and confirm lowest-cost appropriate setting
Dosing concerns Include BSA calculation and FDA labeling reference for weight-based dosing
Non-formulary status Request formulary exception with medical necessity letter

Clinician Corner: Medical Necessity Letter Checklist

When submitting appeals, include:

  • Problem statement: Relapsed/refractory multiple myeloma with specific cytogenetics if high-risk
  • Prior treatments: Complete timeline with response duration and toxicity reasons for discontinuation
  • Clinical rationale: Reference NCCN Multiple Myeloma Guidelines or FDA labeling
  • Monitoring plan: Lab schedule and response assessment timeline

Appeals Process for Illinois Residents

Internal Appeals (First Level)

  • Timeline: 180 days from denial date
  • How to submit: Written request via Cigna member portal or mail
  • Response time: 15 business days for pre-service; 24 hours if expedited
  • Required: Copy of denial letter, medical records, prescriber letter

External Review (Illinois Department of Insurance)

If internal appeals fail, Illinois residents can request independent external review:

  • Timeline: Must request within 30 days of final internal denial (stricter than many states)
  • How to file: Contact Illinois Department of Insurance at (877) 527-9431
  • Process: Independent physician reviewer with expertise in multiple myeloma
  • Decision time: 45 days maximum; expedited reviews available
  • Cost: Free to consumers; insurers pay review costs
Note: Illinois' 30-day deadline for external review is shorter than the federal 4-month window. Don't delay if your internal appeal is denied.

Contact Numbers and Support

For Patients

  • Member Services: (800) 997-1654 (24/7)
  • Specialty Pharmacy (Accredo): Number on your ID card or (800) 997-1654
  • TTY/TDD: Dial 711

For Providers

  • Provider Services: (800) 882-4462
  • Prior Authorization Urgent Line: (800) 882-4462
  • Provider Portal: CignaforHCP.com

Illinois-Specific Resources

  • Illinois Department of Insurance: (877) 527-9431
  • Attorney General Health Care Helpline: (877) 305-5145
  • Consumer assistance with appeals and external reviews

Cost Savings and Patient Assistance

Manufacturer Support

  • Janssen CarePath: Copay assistance up to $25,000/year for eligible patients
  • Income requirements: Household income limits apply; uninsured patients may qualify for free drug
  • How to apply: Visit JanssenCarePath.com or call (877) 227-3728

Additional Resources

  • Leukemia & Lymphoma Society: Financial assistance for treatment costs
  • CancerCare: Copay assistance funds for multiple myeloma patients
  • State pharmaceutical assistance: Illinois residents may qualify for additional state programs

Counterforce Health helps patients and clinicians navigate complex prior authorization and appeal processes by analyzing denial letters, gathering evidence-based medical literature, and drafting targeted appeals that align with payer policies. Their platform can help identify the specific reasons for Darzalex denials and create compelling rebuttal letters that cite relevant clinical guidelines and your treatment history.

FAQ

How long does Cigna PA approval take for Darzalex in Illinois? Standard processing is 5 business days. Expedited reviews for urgent cases process within 72 hours. Track status via the provider portal.

What if Darzalex is non-formulary on my Cigna plan? Request a formulary exception with your physician's certification that formulary alternatives were ineffective or contraindicated.

Can I get an expedited appeal in Illinois? Yes, both Cigna internal appeals and Illinois external reviews offer expedited processing if treatment delay would jeopardize your health or recovery.

Does step therapy apply if I failed treatments in another state? Prior therapy records from any state count toward step therapy requirements. Ensure your oncologist includes complete treatment history in the PA request.

What happens if my external review is approved? Cigna must immediately authorize coverage and pay for the treatment. The external review decision is binding on the insurer.

How much will Darzalex cost with Cigna coverage? As a specialty tier drug, expect 20-40% coinsurance after deductible. Exact costs vary by plan. Check your member portal for specific copay amounts.

From our advocates: We've seen many Darzalex approvals succeed on appeal when the initial denial cited "insufficient prior therapy." The key is providing detailed documentation of each prior treatment with specific dates, response duration, and clear reasons for discontinuation. Don't just list medication names—include the clinical story of why each treatment stopped working or caused intolerable side effects.

When working with Counterforce Health, patients often discover that their denials can be overturned by addressing specific gaps in the original submission, such as missing ICD-10 codes or incomplete prior therapy documentation that payers require for multiple myeloma treatments.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Coverage policies vary by plan. Always verify current requirements with Cigna and consult your healthcare team for medical decisions. For personalized assistance with prior authorizations and appeals, contact the Illinois Department of Insurance consumer helpline at (877) 527-9431.

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