By Counterforce Health Team in Tavneos (avacopan) —

Get Tavneos (Avacopan) Approved by Cigna in Michigan: Forms, Appeals & Contact Guide

Answer Box: Getting Started

Cigna covers Tavneos (avacopan) in Michigan with prior authorization for severe ANCA-associated vasculitis (GPA/MPA) when used with standard therapy. Your prescriber must submit clinical documentation through CoverMyMeds or fax to 1-866-873-8279. If denied, internal appeals must be filed within 180 days, followed by Michigan DIFS external review within 127 days. Start today: Have your rheumatologist, nephrologist, or pulmonologist complete the Cigna prior authorization form with your ANCA status, previous treatments, and medical necessity justification.

Table of Contents

  1. Verify Your Plan & Find Forms
  2. Prior Authorization Forms
  3. Submission Portals & Methods
  4. Specialty Pharmacy Setup
  5. Appeals Process for Michigan
  6. Support & Contact Numbers
  7. Michigan Regulatory Resources
  8. Common Denial Reasons & Solutions
  9. Costs & Patient Assistance
  10. FAQ

Verify Your Plan & Find Forms

Before starting your Tavneos (avacopan) approval process, confirm your specific Cigna plan details:

Coverage at a Glance

Requirement What it means Where to find it Source
Prior Authorization Required for all Tavneos prescriptions Cigna formulary, member portal Cigna formulary
Specialty designation Must use Accredo or approved specialty pharmacy Member ID card, customer service Cigna specialty pharmacy
Diagnosis requirement Severe active ANCA-associated vasculitis (GPA/MPA) FDA label, Cigna policy FDA Access Data
Prescriber requirement Rheumatologist, nephrologist, or pulmonologist preferred Cigna PA criteria Contact Cigna for current policy
Adjunctive use Must be combined with standard therapy Clinical documentation required FDA Access Data
Tip: Call the customer service number on your Cigna ID card to verify your specific formulary tier and any plan-specific requirements that may differ from standard policies.

Prior Authorization Forms

Your prescribing physician must complete Cigna's prior authorization request for Tavneos. Here's how to access and submit the correct forms:

Electronic Submission (Preferred)

  • CoverMyMeds platform: Log in and search for "Tavneos avacopan Cigna"
  • EHR integration: Use SureScripts if available in your provider's system
  • PrescriberPoint: Tavneos PA forms

Manual Submission

Required Documentation

Your prescriber should include:

  • Patient demographics and Cigna member ID
  • Prescriber NPI and specialty
  • Diagnosis with ICD-10 code (M31.30 for GPA, M31.7 for MPA)
  • ANCA test results (c-ANCA/PR3 or p-ANCA/MPO positive)
  • Previous treatment history and outcomes
  • Current standard therapy plan (rituximab or cyclophosphamide with corticosteroids)
  • Clinical justification for adjunctive Tavneos use
Note: Electronic submissions through CoverMyMeds typically process faster than fax submissions and provide real-time status updates.

Submission Portals & Methods

For Healthcare Providers

  • Primary portal: CoverMyMeds
  • Cigna provider portal: Access through Cigna healthcare provider login
  • Fax backup: 1-866-873-8279 (include cover sheet with patient info)

For Patients

  • myCigna portal: Track PA status and appeals
  • Phone support: 1-800-882-4462
  • Mobile app: Cigna mobile app for status updates

Document Upload Requirements

When submitting supporting documentation:

  • Lab results showing ANCA positivity
  • Clinical notes documenting disease severity
  • Previous treatment records (medication trials, dosing, outcomes)
  • Imaging or biopsy results if available
  • Liver function tests (required for Tavneos monitoring)

Specialty Pharmacy Setup

Tavneos requires specialty pharmacy dispensing through Cigna's network, typically Accredo:

Enrollment Process

  1. Automatic transfer: Existing specialty prescriptions may transfer automatically to Accredo
  2. New enrollment: Call 1-800-596-7701 to set up your account
  3. Prescriber coordination: Your doctor can fax prescriptions to 888-302-1028

Patient Portal Access

  • Log into myCigna to manage Accredo prescriptions
  • Set delivery preferences and refill schedules
  • Access 24/7 pharmacy support for complex therapies
  • Coordinate copay assistance programs

Delivery Details

  • Shipping: Free home delivery with temperature-controlled packaging
  • Scheduling: Coordinate delivery based on your availability
  • Supplies: Includes any necessary administration supplies
  • Emergency fills: Available in certain circumstances (verify with Accredo)
From our advocates: One patient found success by proactively calling Accredo immediately after their PA approval to expedite the first shipment, avoiding delays that sometimes occur during the initial specialty pharmacy setup.

Appeals Process for Michigan

If your Tavneos prior authorization is denied, Michigan provides a structured appeals pathway:

Internal Appeals with Cigna

  • Timeline: Must file within 180 days of denial
  • Method: Call 1-800-882-4462 or submit through myCigna portal
  • Required documents: Denial letter, additional clinical evidence, prescriber statement
  • Decision timeline: 60 days for standard appeals, 24-48 hours for expedited

Michigan External Review

After exhausting Cigna's internal appeals, you can request independent review through Michigan DIFS:

Key Details:

  • Deadline: 127 days from final Cigna denial
  • Cost: Free to patients
  • Timeline: 60 days standard, 72 hours expedited
  • Decision: Binding on Cigna if approved

Required Forms:

Submission Methods:

  • Mail: DIFS Office of Appeals, PO Box 30220, Lansing, MI 48909-7720
  • Fax: 517-284-8838
  • Email: [email protected]
  • Phone assistance: 877-999-6442

Support & Contact Numbers

Cigna Member Services

  • Main number: 1-800-882-4462
  • Prior authorization status: Use main number, select PA option
  • Appeals assistance: Same number, request appeals department
  • Specialty pharmacy: Transfer to Accredo support

Provider Support

  • PA submissions: 1-800-882-4462
  • Peer-to-peer reviews: Request through main number
  • Clinical appeals: Fax to 1-800-390-9745

Accredo Specialty Pharmacy

  • Patient enrollment: 1-800-596-7701
  • Prescription fax: 888-302-1028
  • 24/7 support: Available through patient portal
Tip: When calling Cigna, have your member ID, denial letter (if applicable), and prescriber information ready. Ask for reference numbers for all interactions to track your case.

Michigan Regulatory Resources

Michigan Department of Insurance and Financial Services (DIFS)

Michigan Attorney General

  • Health care fraud division: May assist with billing or coverage disputes
  • Consumer protection: General insurance complaint support

Patient Advocacy Resources

  • Michigan Insurance Alliance: Local consumer advocacy
  • Patient Advocate Foundation: National specialty drug assistance

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Not medically necessary Provide ANCA-positive lab results and disease severity documentation Labs, clinical notes, imaging
Step therapy not met Document previous treatment failures or contraindications Medication history, adverse reactions
Non-formulary drug Request formulary exception with medical necessity letter Prescriber justification, alternative failures
Quantity limit exceeded Justify standard 30mg BID dosing per FDA label FDA prescribing information, clinical rationale
Wrong prescriber type Ensure rheumatologist, nephrologist, or pulmonologist prescribes Prescriber credentials, specialty verification

Medical Necessity Letter Checklist

Your prescriber's letter should include:

  • Confirmed diagnosis of severe active GPA or MPA
  • ANCA test results (c-ANCA/PR3 or p-ANCA/MPO positive)
  • Previous treatment attempts and outcomes
  • Current standard therapy plan
  • Clinical rationale for adding Tavneos
  • Monitoring plan for liver function

Costs & Patient Assistance

Tavneos carries significant costs (approximately $170,000-$210,000 annually), but several assistance programs may help:

Manufacturer Support

  • Amgen patient assistance: Check eligibility at tavneospro.com
  • Copay assistance programs: May reduce out-of-pocket costs for eligible patients
  • Patient access coordinators: Available through Amgen for coverage support

Foundation Assistance

  • Patient Advocate Foundation: Specialty drug assistance programs
  • HealthWell Foundation: May offer grants for vasculitis treatments
  • National Organization for Rare Disorders (NORD): Patient assistance programs

State Programs

  • Michigan pharmaceutical assistance: Limited programs for qualifying residents
  • Medicaid coverage: If eligible, may provide coverage through Michigan's Healthy Michigan program
Note: Counterforce Health specializes in turning insurance denials into successful appeals by identifying specific denial reasons and crafting evidence-backed rebuttals aligned with payer policies. Their platform can help patients and providers navigate complex specialty drug approvals like Tavneos.

FAQ

How long does Cigna prior authorization take for Tavneos in Michigan? Standard PA decisions are typically issued within 72 hours of receiving complete documentation. Electronic submissions through CoverMyMeds may be processed faster than fax submissions.

What if Tavneos isn't on my Cigna formulary? Your prescriber can request a formulary exception by demonstrating medical necessity and providing clinical justification. This requires additional documentation but is often successful for rare disease treatments.

Can I request an expedited appeal if denied? Yes, if your health would be seriously jeopardized by delays, request an expedited internal appeal (24-48 hour decision) and potentially expedited external review through Michigan DIFS (72 hours).

Does step therapy apply if I've tried treatments outside Michigan? Yes, properly documented treatment trials from other states count toward step therapy requirements. Ensure your provider includes complete medication history and outcomes.

What happens if my external review is approved? The decision is binding on Cigna, and they must provide coverage as directed by the independent review organization. You'll receive written notification of the decision.

How do I transfer my prescription to Accredo specialty pharmacy? Accredo may automatically transfer existing specialty prescriptions, or your provider can fax new prescriptions to 888-302-1028. Call 1-800-596-7701 to set up your patient account.

When navigating Tavneos coverage with Cigna in Michigan, persistence and proper documentation are key. Counterforce Health helps patients and clinicians turn denials into targeted appeals by analyzing specific payer policies and crafting point-by-point rebuttals with the right clinical evidence and procedural requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies may vary by plan and change over time. Always verify current requirements with Cigna and consult your healthcare provider for medical decisions. For specific coverage questions, contact Cigna customer service or consult the Michigan Department of Insurance and Financial Services.

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