Get Emgality (galcanezumab-gnlm) Covered by Cigna in California: Complete Guide to Prior Authorization and Appeals
Quick Answer: Getting Emgality Covered by Cigna in California
Yes, Cigna covers Emgality (galcanezumab-gnlm) for migraine prevention and episodic cluster headache, but requires prior authorization. Your doctor must document that you have ≥4 migraine days per month and have tried/failed at least 2 standard preventive medications. If denied, California offers strong appeal rights through DMHC Independent Medical Review with high success rates.
First step today: Ask your doctor to submit a prior authorization request through Cigna's provider portal or by calling (800) 882-4462. Have your migraine diary and list of failed medications ready.
Table of Contents
- Is Emgality Covered by Cigna?
- Prior Authorization Process
- Medical Necessity Requirements
- Common Denial Reasons & Solutions
- Appeals Process in California
- Specialty Pharmacy Transfer
- Cost-Saving Options
- Frequently Asked Questions
Is Emgality Covered by Cigna?
Emgality (galcanezumab-gnlm) is included on Cigna's National Formulary as a specialty medication requiring prior authorization. Coverage applies to two FDA-approved indications:
- Migraine prevention in adults (monthly 120 mg injections after initial loading dose)
- Episodic cluster headache treatment (300 mg monthly during cluster periods)
Most Cigna plans in California place Emgality on specialty tiers, typically requiring you to use Accredo specialty pharmacy for fills after initial approval.
Prior Authorization Process
Who Submits the Request
Your prescribing doctor must submit the prior authorization—patients cannot file PA requests directly. Your healthcare provider can submit through:
- Electronic portals: EviCore by Evernorth, SureScripts, or CoverMyMeds
- Phone: (800) 882-4462
- Fax: (855) 840-1678
Step-by-Step: Fastest Path to Approval
- Doctor gathers documentation (1-2 days)
- Migraine diary showing frequency/severity
- Records of prior preventive medication trials and failures
- Current diagnosis and ICD-10 codes
- Submit PA request (same day)
- Use Cigna's CGRP Inhibitors PA form
- Include all required clinical documentation
- Cigna review (5-7 business days standard)
- Clinical pharmacists review against coverage criteria
- May request additional information
- If approved: Prescription transfers to Accredo specialty pharmacy
- If denied: Internal appeal process begins (see Appeals section)
Medical Necessity Requirements
Coverage Criteria for Migraine Prevention
Cigna approves Emgality for migraine prevention when all of the following are met:
| Requirement | Documentation Needed |
|---|---|
| FDA-approved indication | Diagnosis of migraine per ICHD-3 criteria |
| Frequency threshold | ≥4 migraine headache days per month |
| Prior therapy failures | Inadequate response to 2+ standard preventives |
| Medical necessity | Physician attestation of clinical need |
Standard Preventive Medications (Step Therapy)
Before approving Emgality, Cigna typically requires documented trials of:
- Beta-blockers: propranolol, metoprolol
- Anticonvulsants: topiramate, valproate
- Antidepressants: amitriptyline, venlafaxine
- Other options: candesartan, riboflavin
Tip: Keep detailed records of each medication tried, including doses, duration, side effects, and reasons for discontinuation.
Common Denial Reasons & Solutions
| Denial Reason | How to Overturn |
|---|---|
| Insufficient migraine frequency | Submit 3-month migraine diary showing ≥4 days/month |
| Inadequate step therapy | Document specific dates, doses, and outcomes of 2+ preventives |
| Non-formulary status | Request formulary exception with medical necessity letter |
| Quantity limits exceeded | Physician justification for dosing requirements |
| Missing documentation | Resubmit with complete clinical records and PA form |
Medical Necessity Letter Checklist
Your doctor's appeal letter should include:
- Patient history: Migraine pattern, frequency, disability impact
- Prior treatments: Specific medications, doses, trial duration, outcomes
- Clinical rationale: Why Emgality is appropriate based on guidelines
- Supporting evidence: FDA labeling, clinical studies, specialty society recommendations
Appeals Process in California
California residents have exceptionally strong appeal rights through the Department of Managed Health Care (DMHC).
Internal Appeals with Cigna
Timeline: Must file within 180 days of denial Process: Submit written appeal to Cigna with supporting documentation Decision: 30-60 days standard; 72 hours if expedited for urgent need
Call Cigna at (800) 882-4462 to initiate your internal appeal.
California Independent Medical Review (IMR)
If Cigna upholds the denial, California residents can request an Independent Medical Review through DMHC—a powerful external appeal process.
| Review Type | Timeline | Success Rate |
|---|---|---|
| Standard IMR | 30 days | ~50% overturn historically |
| Expedited IMR | 3 days | Higher for urgent cases |
How to file: Submit DMHC's IMR application within 6 months of Cigna's final denial.
Key advantage: IMR decisions are binding on Cigna—if approved, they must authorize coverage.
Note: The IMR process is free to patients. DMHC covers all review costs.
When to Escalate Further
Contact the DMHC Help Center at (888) 466-2219 if:
- Cigna doesn't respond to appeals within required timeframes
- You need help filing an IMR
- You believe Cigna isn't following California insurance regulations
Specialty Pharmacy Transfer
Once approved, Emgality prescriptions automatically transfer to Accredo specialty pharmacy, Cigna's preferred specialty provider.
What to expect:
- Accredo calls to schedule delivery and review injection training
- Free home delivery with refrigerated shipping
- Copay assistance coordination
- 24/7 pharmacist and nurse support
Contact Accredo: (877) 826-7657 for questions about specialty medication orders.
Cost-Saving Options
Manufacturer Support Programs
Lilly Cares Foundation: Provides free Emgality to eligible uninsured patients Emgality Savings Program: Copay assistance for commercially insured patients (restrictions apply for government insurance)
California-Specific Resources
- Covered California plans: May have different formulary tiers—compare during open enrollment
- Medi-Cal: Covers Emgality through managed care plans with prior authorization
Frequently Asked Questions
Q: How long does Cigna prior authorization take in California? A: Standard PA decisions take 5-7 business days. Expedited reviews for urgent cases are decided within 72 hours.
Q: What if Emgality is non-formulary on my plan? A: Request a formulary exception through Cigna's exception process. Your doctor must demonstrate medical necessity.
Q: Can I request an expedited appeal in California? A: Yes, both Cigna internal appeals and DMHC IMRs offer expedited pathways when delays could seriously jeopardize your health.
Q: Does step therapy apply if I tried medications outside California? A: Yes, documented trials from any state count toward step therapy requirements. Ensure your new California doctor has complete records.
Q: What's the success rate for Emgality appeals? A: While specific Emgality data isn't published, California IMRs historically overturn ~50% of denials, with higher rates for specialty medications with strong clinical evidence.
Q: How often do I need to renew prior authorization? A: Cigna typically approves CGRP inhibitors like Emgality for 1-year periods, requiring annual reauthorization.
About Counterforce Health: Counterforce Health specializes in turning insurance denials into successful appeals by creating targeted, evidence-backed responses that align with each payer's specific criteria. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeal processes more effectively.
If you're facing challenges with your Emgality coverage, Counterforce Health can help streamline the appeal process by identifying the specific denial reasons and crafting responses that directly address Cigna's coverage policies and California's regulatory requirements.
Sources & Further Reading
- Cigna CGRP Inhibitors Coverage Policy (PDF)
- Cigna Specialty Pharmacy Information
- California DMHC Independent Medical Review
- Cigna Appeals and Disputes Process
- Accredo Specialty Pharmacy
Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan terms and individual circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For official California insurance regulations and consumer assistance, visit healthhelp.ca.gov or call the DMHC Help Center at (888) 466-2219.
Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.