By Counterforce Health Team in Uplizna (inebilizumab) —

Get Uplizna (Inebilizumab) Covered by Cigna in Ohio: Decision Tree & Appeals Guide

Answer Box: Your Path to Uplizna Coverage in Ohio

To get Uplizna (inebilizumab) covered by Cigna in Ohio: First, confirm your diagnosis (AQP4-positive NMOSD or IgG4-related disease) and complete required lab screening (HBV, TB). Your specialist must submit a prior authorization through Express Scripts ePA portal or by calling 1-800-882-4462. If denied, you have 180 days for internal appeals, then can request external review through the Ohio Department of Insurance (1-800-686-1526). Most denials can be overturned with proper documentation.

Table of Contents

  1. How to Use This Guide
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible": Document Checklist
  4. If "Possibly Eligible": Tests to Request
  5. If "Not Yet": Alternative Options
  6. If Denied: Appeal Path Chooser
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & Fixes
  9. Appeals Playbook for Cigna in Ohio
  10. FAQ

How to Use This Guide

This decision tree helps you navigate Cigna's prior authorization process for Uplizna (inebilizumab) in Ohio. Start with the eligibility triage to understand where you stand, then follow the appropriate path based on your situation.

Note: Uplizna was FDA-approved for IgG4-related disease in April 2025, expanding beyond its original NMOSD indication.

Eligibility Triage: Do You Qualify?

✅ Likely Eligible If You Have:

  • Confirmed diagnosis of AQP4-IgG positive NMOSD OR IgG4-related disease
  • Specialist involvement (neurologist for NMOSD, rheumatologist for IgG4-RD)
  • Required lab screening completed (HBV negative, TB negative)
  • Documentation of disease activity or inadequate response to standard therapies

⚠️ Possibly Eligible If You Have:

  • Clinical symptoms consistent with NMOSD or IgG4-RD but incomplete testing
  • Some specialist involvement but missing key documentation
  • Previous treatment failures but incomplete documentation

❌ Not Yet Eligible If You Have:

  • Unconfirmed diagnosis or missing AQP4 testing (for NMOSD)
  • No specialist evaluation
  • Active HBV or TB infection
  • Missing required baseline labs

If "Likely Eligible": Document Checklist

Required Documentation for Prior Authorization

Medical Records:

  • Specialist consultation notes (neurologist for NMOSD, rheumatologist for IgG4-RD)
  • Laboratory results: AQP4-IgG positive (for NMOSD), elevated IgG4 levels (for IgG4-RD)
  • HBV screening results (surface antigen, core antibody, surface antibody)
  • TB screening (chest X-ray, interferon-gamma release assay or tuberculin skin test)
  • Baseline immunoglobulin levels

Clinical Documentation:

  • Disease activity evidence (MRI findings, organ involvement, symptom progression)
  • Previous treatment history and outcomes
  • Current medications and contraindications

Submission Path

  1. Electronic Prior Authorization (preferred): Use CoverMyMeds or Surescripts ePA
  2. Phone: Call Express Scripts at 1-800-882-4462
  3. Fax: Submit completed forms to number provided by Express Scripts
Tip: Electronic submissions typically process faster and provide real-time status updates.

If "Possibly Eligible": Tests to Request

Missing AQP4 Testing (NMOSD)

Request AQP4-IgG antibody testing from your neurologist. This is mandatory for Uplizna approval in NMOSD cases.

Incomplete IgG4-RD Workup

  • Serum IgG4 levels
  • Tissue biopsy (if indicated)
  • Imaging studies showing organ involvement
  • Exclusion of malignancy or other autoimmune conditions

Required Screening Labs

  • Hepatitis B panel (surface antigen, core antibody, surface antibody)
  • TB screening (chest imaging, IGRA or TST)
  • Complete blood count with differential
  • Comprehensive metabolic panel

Timeline to Re-apply: Allow 2-4 weeks for test results, then resubmit prior authorization with complete documentation.

If "Not Yet": Alternative Options

While Building Your Case

For NMOSD:

For IgG4-RD:

  • Corticosteroid therapy (standard first-line)
  • Immunosuppressive agents (methotrexate, azathioprine)

Preparing for Exception Requests

If standard criteria aren't met, prepare for a formulary exception request by documenting:

  • Why alternatives are unsuitable or contraindicated
  • Unique aspects of your case requiring Uplizna
  • Specialist recommendation with detailed rationale

If Denied: Appeal Path Chooser

Level 1: Internal Appeal with Cigna

  • Timeline: File within 180 days of denial
  • Process: Submit appeal through Cigna member portal or by phone
  • Documentation: Include all supporting medical records and specialist letters

Level 2: Peer-to-Peer Review

Request your prescriber initiate a peer-to-peer discussion with Cigna's medical director. This often resolves complex specialty drug denials.

Level 3: External Review (Ohio)

  • Eligibility: After completing internal appeals
  • Timeline: Request within 60 days of final internal denial
  • Process: File with Ohio Department of Insurance
  • Cost: Free to you (insurer pays IRO fees)
From our advocates: We've seen many Uplizna denials overturned at the peer-to-peer level when the prescriber clearly explains why standard alternatives failed or are contraindicated. Having all lab results and imaging readily available for the call makes a significant difference.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before dispensing Express Scripts portal or phone Express Scripts PA FAQ
Diagnosis Confirmation AQP4+ NMOSD or IgG4-RD Specialist evaluation and labs FDA Label
HBV Screening Must be negative for active infection Lab results in PA submission Uplizna Prescribing Information
Specialist Prescriber Neurologist (NMOSD) or Rheumatologist (IgG4-RD) Provider credentials UnitedHealthcare Policy
Site of Care Typically outpatient infusion center Prior authorization approval Cigna Site of Care Guidance

Common Denial Reasons & Fixes

Denial Reason How to Overturn
"Not AQP4-positive" Submit lab results showing AQP4-IgG positivity
"Experimental for IgG4-RD" Reference April 2025 FDA approval with indication
"Missing HBV screening" Provide complete hepatitis B panel results
"Inadequate specialist involvement" Include detailed neurologist or rheumatologist consultation
"Step therapy required" Document failures/contraindications to required alternatives
"Site of care not approved" Request authorization for appropriate infusion facility

Appeals Playbook for Cigna in Ohio

Internal Appeals

  • First Level: Submit through Cigna member portal or call customer service
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Required: All medical records, specialist letters, lab results

Expedited Appeals

Available when delay could "seriously jeopardize life, health, or ability to regain maximum function." Your doctor must certify the urgency.

External Review Process

  1. Complete internal appeals first (required in most cases)
  2. File within 60 days of final internal denial
  3. Submit to: Your health plan (they notify Ohio DOI)
  4. Timeline: 30 days for standard, 72 hours for expedited
  5. Decision: Binding on insurer if approved

Ohio Consumer Hotline: 1-800-686-1526 for assistance with the appeals process.

FAQ

How long does Cigna prior authorization take for Uplizna in Ohio? Standard review is typically completed within 72 hours of receiving complete documentation. Expedited review (for urgent cases) is processed within 24 hours.

What if Uplizna is non-formulary on my Cigna plan? You can request a formulary exception with your prescriber providing clinical justification for why formulary alternatives are unsuitable.

Can I request an expedited appeal in Ohio? Yes, if your treating physician certifies that waiting for standard review could seriously endanger your health. Both Cigna and Ohio's external review process offer expedited options.

Does step therapy apply if I've tried treatments outside Ohio? Yes, document all previous treatments regardless of where you received them. Cigna will consider your complete treatment history.

How much does Uplizna cost without insurance? The list price is approximately $140,248 per dose, with year one costs around $420,000 (three doses) and subsequent years around $280,000 (two doses annually).

What manufacturer support is available? Amgen offers the Amgen by Your Side program providing financial assistance and care coordination support for eligible patients.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to draft targeted, evidence-backed rebuttals. Their platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeals processes for medications like Uplizna.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan and clinical circumstances. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For assistance with Ohio insurance appeals, contact the Ohio Department of Insurance at 1-800-686-1526.

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