By Counterforce Health Team in Alecensa (alectinib) — 06 Nov 2025

Getting Alecensa (Alectinib) Covered by Cigna in Georgia: Prior Authorization, Appeals, and Formulary Alternatives

Answer Box: Getting Alecensa Covered by Cigna in Georgia

Cigna covers Alecensa (alectinib) for ALK-positive NSCLC in Georgia, but requires prior authorization and may impose step therapy. Your fastest path: 1) Have your oncologist submit a prior authorization request with ALK-positive test results and medical necessity documentation, 2) If denied, file an internal appeal within 180 days, 3) Request external review through Georgia's Department of Insurance within 60 days of final denial. Start today by calling Cigna Member Services at the number on your card to confirm your plan's formulary status and PA requirements.

Coverage at a Glance
When Formulary Alternatives Make Sense
Typical ALK Inhibitor Alternatives
Pros and Cons Overview
Exception Strategy: When to Request Alecensa
Switching Logistics and Coordination
Re-trying for Alecensa Later
Appeals Playbook for Georgia
Common Denial Reasons and Fixes
FAQ

Coverage at a Glance

Requirement	What It Means	Where to Find It	Source
Prior Authorization	Required for specialty tier coverage	Member formulary or call Cigna	Cigna Formulary
Formulary Tier	Specialty Tier 5 (highest cost-sharing)	2024 Cigna formulary documents	Medicare Formulary
Step Therapy	May require trying another ALK inhibitor first	Prior auth determination	Coverage Policy
Appeals Deadline	180 days for internal; 60 days for external in GA	Denial letter	GA Insurance Dept
Medical Necessity	ALK+ test results, prior therapy failures	Oncologist's records	FDA Label Requirements

When Formulary Alternatives Make Sense

Before pursuing an exception for Alecensa, it's worth understanding when Cigna's formulary alternatives might be appropriate. Cigna typically covers other ALK inhibitors that may be clinically suitable depending on your specific situation.

Consider alternatives when:

You haven't tried other ALK inhibitors yet
Cost-sharing for Alecensa would create financial hardship
Your oncologist believes another agent offers similar efficacy
You're treatment-naive (first-line therapy)

Don't settle for alternatives if:

You've already failed or had intolerable side effects with other ALK inhibitors
You have CNS metastases requiring Alecensa's superior brain penetration
Your oncologist specifically recommends Alecensa based on your mutation profile
You're currently stable on Alecensa and switching would disrupt treatment

Tip: Always discuss the clinical rationale with your oncologist before accepting or rejecting alternatives. The "best" drug varies by patient.

Typical ALK Inhibitor Alternatives

Cigna's formulary typically includes these ALK inhibitors, though coverage varies by specific plan:

First-Generation

Crizotinib (Xalkori): Often the required "step therapy" option
- Lower cost, established safety profile
- Limited CNS activity, higher resistance rates

Second-Generation Options

Ceritinib (Zykadia): May be formulary-preferred
- Strong efficacy, including CNS activity
- Higher GI toxicity rates than Alecensa
Brigatinib (Alunbrig): Newer second-generation option
- Excellent CNS penetration
- Risk of early pulmonary toxicity requiring monitoring

Third-Generation

Lorlatinib (Lorbrena): For resistant cases
- Broad mutation coverage
- Typically reserved for later lines

Note: Specific formulary placement changes annually. Verify current coverage with your 2024-2025 plan documents.

Pros and Cons Overview

Drug	Access Considerations	Testing Requirements	Monitoring Needs
Crizotinib	Usually formulary-preferred	ALK+ confirmation only	Vision checks, testosterone levels
Ceritinib	May require PA	ALK+ confirmation	Intensive GI toxicity monitoring
Brigatinib	Often non-formulary	ALK+ confirmation	Early pulmonary toxicity surveillance
Alecensa	Typically requires exception	ALK+ confirmation	LFTs, CPK, renal function
Lorlatinib	Reserved for progression	Resistance mutation testing helpful	Neuropsychiatric monitoring

Key considerations for Georgia patients:

Specialty pharmacy requirement: Most ALK inhibitors must be filled through Cigna's specialty pharmacy (typically Accredo)
Prior authorization timelines: Standard decisions within 72 hours; expedited within 24 hours
Cost-sharing: Specialty tier drugs often have 25-40% coinsurance rather than fixed copays

Exception Strategy: When to Request Alecensa

Request an Alecensa formulary exception when you have strong medical necessity documentation:

Strongest Cases

Prior ALK inhibitor failure: Documented progression or intolerable toxicity with crizotinib, ceritinib, or brigatinib
CNS metastases: Alecensa's superior brain penetration makes it medically necessary
Contraindications to alternatives: Specific medical reasons other ALK inhibitors are inappropriate
Currently stable on Alecensa: If you're already responding well and switching would be disruptive

Required Documentation

Your oncologist should submit:

ALK-positive test results (FISH, IHC, or NGS)
Complete treatment history with specific dates, drugs, doses, and outcomes
Imaging showing progression on prior therapies
Toxicity documentation (lab values, adverse event reports)
Medical necessity letter citing NCCN guidelines and FDA indications

From our advocates: We've seen successful Alecensa appeals in Georgia when oncologists included specific details about why alternatives failed—not just "patient didn't tolerate" but "Grade 3 hepatotoxicity requiring hospitalization" with actual lab values. The more specific the documentation, the stronger the case.

Counterforce Health specializes in turning insurance denials into evidence-backed appeals by identifying the specific denial basis and crafting point-by-point rebuttals aligned to each payer's own rules. Their platform helps oncology practices streamline prior authorization requests with the right clinical facts and citations.

Switching Logistics and Coordination

If you need to try an alternative before getting Alecensa approved, proper coordination prevents treatment gaps:

Before Switching

Confirm insurance coverage for the alternative drug
Schedule baseline labs required for the new agent
Coordinate with specialty pharmacy (likely Accredo for Cigna)
Plan monitoring schedule with your oncology team

During Transition

Minimize therapy interruption: Most ALK inhibitors can be switched without washout periods
Document everything: Keep detailed records of response, side effects, and tolerability
Maintain communication: Regular check-ins between oncology clinic and specialty pharmacy

If Alternative Fails

This becomes your strongest evidence for an Alecensa exception. Document:

Specific reason for failure (progression, toxicity, intolerance)
Timeline and duration of the trial
Objective measures (scans, lab values, symptom scores)
Clinical impact on quality of life or disease control

Re-trying for Alecensa Later

What to document during your alternative trial:

Clinical Response

Baseline and follow-up imaging results
Tumor marker trends (if applicable)
Performance status changes
Symptom improvement or worsening

Toxicity Profile

All adverse events, graded by severity
Lab abnormalities with specific values
Dose reductions or treatment delays
Impact on daily activities

Quality of Life

Patient-reported outcomes
Functional status changes
Treatment adherence challenges
Caregiver burden

This documentation becomes the foundation for your Alecensa medical necessity case when the alternative proves inadequate.

Appeals Playbook for Georgia

Internal Appeals with Cigna

Timeline: 180 days from denial date Process:

Submit written appeal with additional clinical documentation
Cigna reviews within 30 days (expedited: 72 hours)
If denied, proceed to second-level internal review

Required documents:

Original denial letter
Updated medical necessity letter
New clinical evidence (labs, scans, progress notes)
Treatment failure documentation

External Review in Georgia

Timeline: 60 days from final internal denial Process:

Submit application to Georgia Department of Insurance
Independent medical review by specialty physicians
Decision within 30 business days (expedited: 72 hours)

Key advantage: External review is binding on Cigna and free for you as the patient.

Contact: Georgia Insurance Consumer Services: 1-800-656-2298

Common Denial Reasons and Fixes

Denial Reason	How to Overturn
"Not medically necessary"	Submit NCCN guidelines showing Alecensa as preferred option for ALK+ NSCLC
"Step therapy required"	Document failure/intolerance of required first-line agent with specific clinical details
"Experimental/investigational"	Provide FDA approval letter and indication-specific labeling
"Alternative available"	Clinical comparison showing why alternatives are inappropriate for this patient
"Insufficient documentation"	Complete ALK testing, staging, and treatment history with dates and outcomes

Working with Counterforce Health can help identify the specific denial basis and draft targeted rebuttals that address Cigna's exact concerns with the right clinical evidence.

FAQ

How long does Cigna prior authorization take in Georgia? Standard PA decisions within 72 hours; expedited reviews within 24 hours for urgent cases. Appeals take 30 days for internal review, 30 business days for external review.

What if Alecensa is non-formulary on my Cigna plan? You can request a formulary exception with medical necessity documentation. Success rates improve significantly when you provide evidence of alternative therapy failures.

Can I request an expedited appeal in Georgia? Yes, if delay would seriously jeopardize your health. Both Cigna internal appeals and Georgia external reviews offer expedited pathways (72 hours or less).

Does step therapy apply if I failed ALK inhibitors outside Georgia? Yes, documented treatment failures from other states count as step therapy completion. Ensure your Georgia oncologist has complete records from previous providers.

What's the success rate for Alecensa appeals? While specific data varies, appeals with strong medical necessity documentation (prior failures, contraindications, specialty guidelines) have substantially higher approval rates than initial requests.

How much does Alecensa cost with Cigna coverage? On specialty tiers, expect 25-40% coinsurance. For a $19,466 monthly supply, that's roughly $4,900-$7,800 per month. Manufacturer copay assistance and foundation grants may help reduce costs.

What if I can't afford Alecensa even with insurance? Genentech offers patient assistance programs, and organizations like CancerCare provide financial support. Georgia also has prescription assistance programs for qualifying residents.

Can I appeal to the state if Cigna keeps denying? Yes, Georgia's external review process provides independent medical review that's binding on Cigna. This is often more successful than repeated internal appeals.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance company for personalized guidance.

Sources & Further Reading

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