By Counterforce Health Team in Xospata (gilteritinib) —

Get Xospata (Gilteritinib) Covered by Cigna in Virginia: Provider Partnership Guide with Forms and Appeals

Answer Box: Fast Track to Xospata Coverage

Xospata (gilteritinib) requires prior authorization from Cigna in Virginia for relapsed/refractory AML with confirmed FLT3 mutations. Your hematologist-oncologist must submit documentation through Express Scripts/Accredo or EviCore pathways. Key requirements: FLT3 mutation test results, prior therapy history, and medical necessity letter. Standard approval takes 2 days with complete documentation; expedited review available for urgent cases (24 hours). If denied, Virginia offers external review through the State Corporation Commission Bureau of Insurance with expedited cancer treatment appeals decided within 72 hours.

Start today: Call Cigna member services (number on your ID card) to confirm prior authorization requirements and specialty pharmacy coverage through Accredo.

Table of Contents

  1. Set Your Goal: Understanding Cigna's Requirements
  2. Visit Preparation: Organizing Your Medical History
  3. Building Your Evidence Kit
  4. Medical Necessity Letter Structure
  5. Supporting Peer-to-Peer Reviews
  6. After-Visit Documentation
  7. Appeals Process in Virginia
  8. Cost and Assistance Programs
  9. FAQ

Set Your Goal: Understanding Cigna's Requirements

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Doctor must get approval before prescribing Express Scripts PA portal Express Scripts
FLT3 Mutation Test Lab-confirmed ITD or TKD mutation required Blood/bone marrow from CLIA-certified lab FDA Access Data
Specialty Pharmacy Must use Accredo for dispensing Accredo enrollment Cigna Specialty
Hematologist Prescriber Must be prescribed by oncology specialist Medical license verification Cigna Coverage Policy

Partnership Strategy

Working with your hematologist-oncologist is essential—patients cannot submit prior authorizations directly. Your role focuses on gathering documentation and ensuring your provider has complete information for the strongest possible submission.

Tip: Schedule a dedicated appointment to discuss insurance approval strategy. This isn't typically covered in routine follow-ups and deserves focused time.

Visit Preparation: Organizing Your Medical History

Essential Documentation Checklist

Before your appointment, gather:

Insurance Information:

  • Current Cigna member ID card
  • Summary of benefits (available through myCigna.com)
  • Previous denial letters (if applicable)

Medical History:

  • Complete list of prior AML treatments with dates
  • Reasons for discontinuation (progression, intolerance, side effects)
  • Current functional status and symptoms
  • Recent lab results and bone marrow biopsy reports

Treatment Timeline: Create a simple chronological list:

  1. Initial diagnosis date and staging
  2. First-line therapy (drug names, dates, response)
  3. Subsequent treatments and outcomes
  4. Current disease status

Symptom and Function Documentation

Your doctor needs to document how AML affects your daily life. Prepare to discuss:

  • Energy levels and fatigue patterns
  • Infections or bleeding episodes
  • Work or activity limitations
  • Quality of life impact

Building Your Evidence Kit

Required Laboratory Evidence

FLT3 Mutation Testing:

  • Must be from FDA-approved test method
  • Include both ITD and TKD mutation status
  • Ensure report is from CLIA-certified laboratory
  • Request copy for your records

Supporting Labs:

  • Complete blood count with differential
  • Comprehensive metabolic panel
  • Recent bone marrow biopsy results
  • Flow cytometry if available

Published Guidelines Support

Your hematologist will reference:

  • NCCN Guidelines for AML (subscription required)
  • FDA-approved labeling for relapsed/refractory FLT3+ AML
  • Peer-reviewed studies supporting gilteritinib use

Medical Necessity Letter Structure

Clinician Corner: Letter of Medical Necessity Checklist

Your hematologist should include these elements on letterhead with NPI:

Patient Demographics:

  • Full name, date of birth, member ID
  • AML diagnosis with ICD-10 code
  • Confirmation of age ≥18 years

Disease Documentation:

  • Specific FLT3 mutation type (ITD/TKD)
  • Laboratory report date and methodology
  • Evidence of relapsed or refractory disease
  • Current disease burden and symptoms

Treatment History:

  • Complete prior therapy list with dates
  • Response to each treatment
  • Reasons for discontinuation
  • Documentation of treatment failures

Clinical Rationale:

  • Why Xospata 120 mg daily is appropriate next-line therapy
  • Reference to NCCN guidelines
  • Treatment goals (remission, survival benefit)
  • Monitoring plan for side effects
  • Expected treatment duration

Manufacturer Resources: Astellas provides sample letters and support through XOSPATA Support Solutions.

Supporting Peer-to-Peer Reviews

When Cigna Requests Provider Discussion

If initial prior authorization is denied, Cigna may offer a peer-to-peer review where your hematologist discusses the case directly with a Cigna medical director.

How You Can Help:

  • Provide flexible scheduling windows for your doctor
  • Prepare a one-page case summary highlighting:
    • Failed prior therapies
    • Current symptoms and functional impact
    • Urgency of treatment initiation

Key Discussion Points for Your Provider:

  • FLT3 mutation confirmation and testing methodology
  • Prior therapy failures and contraindications
  • Alignment with FDA labeling and NCCN guidelines
  • Patient-specific factors favoring gilteritinib

After-Visit Documentation

What to Save and Track

From Your Provider:

  • Copy of prior authorization submission
  • Confirmation number or reference ID
  • Expected timeline for decision
  • Contact information for follow-up

Insurance Communications:

  • All correspondence from Cigna/Express Scripts
  • Approval or denial letters
  • Claims and explanation of benefits (EOB)

Portal Messaging: Use your patient portal to:

  • Request copies of submitted documents
  • Ask for updates on authorization status
  • Schedule follow-up appointments

Respectful Persistence Timeline

  • Week 1: Initial submission by provider
  • Week 2: Follow up if no response received
  • Week 3: Escalate to office manager if needed
  • Beyond 3 weeks: Consider expedited review request

Appeals Process in Virginia

Internal Appeals with Cigna

First Level:

  • Must be filed within 180 days of denial
  • Submit via Cigna provider portal or fax
  • Standard review: 30 days
  • Expedited review: 72 hours for urgent cases

Required Documentation:

  • Original denial letter
  • Enhanced medical necessity letter addressing denial reasons
  • Additional clinical evidence or guidelines
  • Provider attestation of medical necessity

Virginia External Review Process

If internal appeals fail, Virginia law provides independent external review through the State Corporation Commission Bureau of Insurance.

Timeline for Cancer Treatment Appeals:

Step Standard Review Expedited Review
File Form 216-A Within 120 days of final denial Immediately if urgent
Carrier eligibility review 5 business days Immediately
IRO assignment 1 business day Immediately
Final decision 45 days total 72 hours

Expedited Review Criteria:

  • Serious jeopardy to life or health if delayed
  • Oncologist certification of urgency required
  • Available for ongoing cancer treatment needs

How to File:

  1. Download Form 216-A from SCC website
  2. Include all medical records and provider recommendations
  3. Submit within 120 days of final denial
  4. No cost to patient for external review
Virginia Advantage: Virginia allows expedited external review for cancer treatment without completing all internal appeal levels in urgent situations.

Cost and Assistance Programs

Manufacturer Support

XOSPATA Support Solutions:

  • Patient enrollment assistance
  • Insurance verification services
  • Copay assistance program (verify eligibility)
  • Forms and resources

Financial Assistance Options

Estimated Costs:

  • Wholesale acquisition cost: $28,979 for 30-day supply
  • Patient out-of-pocket varies by plan design
  • Specialty tier copays typically $100-500+ per month

Additional Resources:

  • CancerCare financial assistance
  • Leukemia & Lymphoma Society support programs
  • State pharmaceutical assistance programs

When Coverage Gets Complex

Sometimes standard processes aren't enough. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to identify specific denial reasons—whether PA criteria, step therapy, or "not medically necessary" determinations—then drafts point-by-point rebuttals aligned to the plan's own rules.

For complex cases involving multiple denials or unclear coverage policies, specialized appeal support can make the difference between approval and continued delays in accessing needed treatment.

FAQ

How long does Cigna prior authorization take for Xospata in Virginia? Standard review takes 2 business days with complete documentation. Expedited review for urgent cases is completed within 24 hours.

What if Xospata is non-formulary on my Cigna plan? Your doctor can request a formulary exception by documenting medical necessity and why formulary alternatives are inappropriate. Use Cigna's formulary exception process.

Can I request expedited appeals in Virginia? Yes. Virginia allows expedited external review for cancer treatments when delays could seriously jeopardize health. Expedited reviews are decided within 72 hours.

Does step therapy apply if I've failed treatments outside Virginia? Treatment history from any location counts toward step therapy requirements. Ensure your provider documents all prior therapies regardless of where they were received.

What happens if my external review is denied? External review decisions are binding on the insurer and final for the appeals process. You retain rights to legal action or may explore alternative coverage options.

How do I check if my doctor is considered a qualified prescriber? Cigna typically requires hematologist-oncologist prescribing for Xospata. Verify through your provider's credentials or contact Cigna member services.

Can I use patient assistance programs with Cigna coverage? Many patients can use manufacturer copay assistance alongside insurance. Check program terms and discuss with your specialty pharmacy.

What if I need to switch from Accredo specialty pharmacy? Cigna plans often mandate Accredo for specialty medications. Switching may require plan approval or could result in higher out-of-pocket costs.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with your insurer and consult your healthcare provider for medical decisions. For questions about Virginia insurance regulations, contact the State Corporation Commission Bureau of Insurance at 1-877-310-6560.

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