By Counterforce Health Team in Firdapse (amifampridine) —

Get Firdapse (Amifampridine) Covered by Cigna in Washington: Complete Prior Authorization Guide

Quick Answer: Getting Firdapse Covered by Cigna in Washington

To get Firdapse (amifampridine) covered by Cigna in Washington, you need: (1) confirmed LEMS diagnosis with positive antibody testing or EMG, (2) prescription from a neurologist/neuromuscular specialist, (3) no seizure history, and (4) prior authorization submission. If denied, Washington's external review process through an Independent Review Organization (IRO) provides strong consumer protection. First step today: Contact your neurologist to initiate the prior authorization request through Cigna's provider portal.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Setting Your Goal: What Approval Requires
  3. Visit Preparation: Building Your Case
  4. Evidence Kit: Essential Documentation
  5. Medical Necessity Letter Structure
  6. Peer-to-Peer Review Support
  7. After Your Visit: Documentation Strategy
  8. Appeals Process in Washington
  9. Cost-Saving Options
  10. Frequently Asked Questions

Coverage Requirements at a Glance

Requirement Details Source
Age ≥6 years old Cigna Policy
Diagnosis LEMS confirmed by EMG or anti-P/Q VGCC antibodies Cigna Policy
Prescriber Neurologist or neuromuscular specialist Cigna Policy
Contraindications No seizure history (absolute exclusion) Cigna Policy
Step Therapy Not required for LEMS Cigna Policy
Initial Approval 3 months Cigna Policy
Renewal 1 year with continued benefit Cigna Policy

Setting Your Goal: What Approval Requires

Your partnership with your healthcare provider is crucial for securing Firdapse coverage. Unlike many specialty medications, Cigna doesn't require you to fail other treatments first—but you do need rock-solid diagnostic proof and specialist oversight.

Your role: Gather comprehensive medical history, document functional impacts, and maintain organized records of all communications.

Your provider's role: Submit prior authorization with diagnostic evidence, clinical justification, and ongoing monitoring plan.

Note: Firdapse is the only FDA-approved amifampridine product for LEMS after Ruzurgi's approval was withdrawn in 2022, making it the clear first-line choice for confirmed LEMS cases.

Visit Preparation: Building Your Case

Before your neurology appointment, create a detailed timeline that strengthens your case:

Symptom Documentation

  • Onset and progression: When did muscle weakness begin? Which muscles were affected first?
  • Functional impact: Difficulty climbing stairs, getting up from chairs, lifting objects
  • Autonomic symptoms: Dry mouth, constipation, orthostatic hypotension
  • Improvement with activity: Classic LEMS pattern where strength improves with repeated use

Treatment History

Document all previous interventions:

  • Pyridostigmine trials and response
  • IVIG or plasmapheresis treatments
  • Immunosuppressive medications
  • Physical therapy outcomes

Seizure History Screen

Be prepared to confirm you have never had seizures—this is an absolute contraindication that will result in automatic denial.

Evidence Kit: Essential Documentation

Work with your care team to assemble these critical documents:

Diagnostic Tests

  • Anti-P/Q type VGCC antibody results (positive confirms LEMS)
  • EMG/nerve conduction studies showing characteristic LEMS pattern
  • Repetitive nerve stimulation demonstrating incremental response
  • Cancer screening results (50-60% of LEMS cases are paraneoplastic)

Clinical Records

  • Neurology consultation notes with LEMS diagnosis
  • Functional assessment scores (if available)
  • Documentation of weakness patterns and autonomic symptoms
Tip: Request copies of all test results for your personal files. You'll need them if an appeal becomes necessary.

Medical Necessity Letter Structure

Your neurologist will need to craft a compelling medical necessity letter. Here's what should be included:

Essential Components

  1. Clear LEMS Diagnosis
    • ICD-10 code G73.1 (Lambert-Eaton syndrome)
    • Diagnostic method (antibody testing or EMG findings)
    • Date of diagnosis confirmation
  2. Clinical Rationale
    • Functional impairment documentation
    • How LEMS affects daily activities and quality of life
    • Expected treatment response based on clinical guidelines
  3. Treatment Plan
    • Starting dose (typically 15-30 mg daily)
    • Monitoring plan for efficacy and side effects
    • Duration of therapy (chronic, lifelong treatment)
  4. Supporting Evidence

Peer-to-Peer Review Support

If your initial prior authorization is denied, your neurologist can request a peer-to-peer review with Cigna's medical director. Here's how to support this process:

Preparation for Your Provider

  • Availability windows: Provide your doctor's preferred call times
  • Case summary: Prepare a one-page overview of your diagnosis, symptoms, and functional impact
  • Key talking points: Emphasize LEMS rarity, lack of alternatives, and established efficacy

During the Review

Your provider should emphasize:

  • LEMS is a rare, serious condition with significant disability
  • Firdapse is the only FDA-approved treatment
  • No step therapy requirements exist in Cigna's own policy
  • Treatment delay risks permanent functional decline

After Your Visit: Documentation Strategy

Maintain organized records of every interaction:

Save Everything

  • Prior authorization submission confirmations
  • Denial letters with specific reasons
  • Appeal correspondence
  • Provider portal messages

Use Patient Portals

  • Message your provider through secure portals for documented communication
  • Request copies of all submitted forms and letters
  • Track submission dates and response timelines
From our advocates: "One patient kept a simple spreadsheet tracking every call, reference number, and outcome. When they needed to escalate to Washington's external review, this organized timeline helped the IRO understand the full picture and ultimately overturn the denial."

Appeals Process in Washington

Washington provides robust consumer protection through a structured appeals process:

Internal Appeals (First Level)

External Review (Independent Review Organization)

If internal appeals fail, Washington's external review process offers strong consumer protection:

Washington Insurance Commissioner Support

The Office of the Insurance Commissioner provides free consumer advocacy:

  • Consumer hotline: 1-800-562-6900
  • Appeal guidance: Step-by-step assistance
  • Complaint filing: If you feel the process was mishandled

For patients and providers navigating complex prior authorization challenges, Counterforce Health offers specialized support in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and drafts point-by-point rebuttals aligned to payer policies, helping ensure patients get access to essential medications like Firdapse.

Cost-Saving Options

While working on coverage, explore these financial assistance programs:

Manufacturer Support

  • Catalyst Cares Program: Patient assistance for eligible individuals
  • Copay assistance: May reduce out-of-pocket costs for insured patients
  • Information: Contact Catalyst Pharmaceuticals directly

Foundation Grants

  • National Organization for Rare Disorders (NORD): Medication assistance programs
  • HealthWell Foundation: Grants for specialty medication copays
  • Patient Access Network (PAN): Disease-specific assistance funds

Frequently Asked Questions

How long does Cigna prior authorization take for Firdapse? Standard reviews take up to 72 hours. Expedited reviews (for urgent cases) are completed within 24 hours. Your provider can request expedited review if treatment delay poses health risks.

What if Firdapse isn't on Cigna's formulary? Cigna has a formulary exception process for non-formulary medications. Your provider can request an exception with clinical justification.

Can I appeal if I have a seizure history? Unfortunately, seizure history is an absolute contraindication per Cigna's policy and FDA labeling. This exclusion is unlikely to be overturned on appeal.

Does step therapy apply to Firdapse for LEMS? No. Cigna's current policy does not require failure of other medications before approving Firdapse for confirmed LEMS diagnosis.

How do I request expedited review in Washington? Contact Cigna directly and clearly state that treatment delay could seriously jeopardize your health. Provide supporting documentation from your neurologist about the urgency.

What happens if my appeal is denied? You can request external review through Washington's IRO process. This independent medical review is binding on Cigna and free to you.

Can I get help with the appeals process? Yes. Contact the Washington Insurance Commissioner's consumer advocacy line at 1-800-562-6900 for free assistance.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and state regulations may change. Always consult with your healthcare provider and insurance company for the most current information regarding your specific situation. For complex prior authorization challenges, services like Counterforce Health can provide specialized assistance in navigating insurance appeals and ensuring access to essential medications.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.