By Counterforce Health Team in Brineura (cerliponase alfa) —

Getting Brineura (Cerliponase Alfa) Covered by Cigna in Texas: Complete Guide to Forms, Appeals, and Approval

Answer Box: Your Path to Brineura Coverage in Texas

Getting Brineura (cerliponase alfa) covered by Cigna in Texas requires prior authorization with strict medical necessity criteria. The fastest path: Have your child's specialist submit the Cigna Brineura PA form via CoverMyMeds or fax, including genetic testing confirming CLN2 disease and functional assessments. If denied, file an internal appeal within 180 days, then request Texas external review through TDI. Start today: Call Cigna at 1-800-882-4462 to verify your plan's specialty pharmacy requirements and confirm Brineura's formulary status.

Table of Contents

  1. Verify Your Plan and Find the Right Forms
  2. Required Forms and Documentation
  3. Submission Portals and Electronic Options
  4. Fax and Mail Submission Details
  5. Specialty Pharmacy Coordination
  6. Key Contact Numbers and Support
  7. Texas Appeals and External Review
  8. Keeping Resources Current

Verify Your Plan and Find the Right Forms

Before submitting any paperwork, confirm your specific Cigna plan details. Not all Cigna plans are identical—some are state-regulated, others fall under federal ERISA rules, which affects your appeal rights in Texas.

Call Cigna Member Services at the number on your ID card and ask:

  • Is Brineura covered under pharmacy or medical benefits?
  • Which specialty pharmacy is required (Express Scripts or Accredo)?
  • What's the current formulary tier for Brineura?
  • Are there step therapy or quantity limit requirements?
Tip: Write down the representative's name and reference number. You'll need this information if there are discrepancies later.

Find Your Plan's Coverage Policy: Cigna's national Brineura policy requires prior authorization and outlines specific criteria for CLN2 disease coverage. However, your individual plan may have additional restrictions.

Required Forms and Documentation

Core Prior Authorization Form

Use Cigna's "Brineura CCRD Prior Authorization Form" — this is the drug-specific form required for all Brineura requests. The form is available through:

Essential Clinical Documentation

Your specialist must include:

Diagnosis Confirmation:

  • Genetic test results showing TPP1 mutations
  • Enzyme testing confirming TPP1 deficiency
  • ICD-10 code for CLN2 disease
  • Age at symptom onset and current functional status

Disease Monitoring:

  • Recent CLN2 Clinical Rating Scale scores
  • Neurological exam findings
  • EEG and MRI results if available
  • Documentation of seizure history and current management

Treatment History:

  • Prior therapies attempted and outcomes
  • Current medications and their effectiveness
  • Any contraindications to alternative treatments

Surgical and Care Details:

  • ICV device placement documentation
  • Approved infusion center information
  • Administration schedule and monitoring plan

Medical Necessity Letter Template

Your pediatric neurologist should provide a letter addressing each Cigna criterion:

"Patient [Name] is a [age]-year-old with genetically confirmed CLN2 disease (TPP1 deficiency) who meets Cigna's criteria for Brineura coverage:Confirmed CLN2 diagnosis: [Include specific genetic/enzyme test results]Age ≥3 years: Patient is currently [age] years oldSpecialist care: Treatment is prescribed by pediatric neurologist with CLN2 expertiseAppropriate setting: Infusions will occur at [facility name], an approved center

Without Brineura, this child faces rapid, irreversible neurological decline including loss of ambulation, speech, and increased seizure burden. The medication is FDA-approved specifically for slowing functional decline in CLN2 disease, with no therapeutic alternatives available."

Submission Portals and Electronic Options

Website: www.covermymeds.com

How to use:

  1. Search for "Cigna" and "Brineura"
  2. Select the Brineura CCRD Prior Authorization Form
  3. Upload all supporting documents as PDFs
  4. Submit electronically for fastest processing

Advantages: Real-time status tracking, automatic routing to correct Cigna department, electronic confirmation of receipt.

SureScripts Integration

If your clinic uses an EHR system with SureScripts integration, your provider can initiate the PA directly from the e-prescribing workflow. This pulls the same Cigna criteria and routes electronically to Express Scripts or Accredo.

Cigna Provider Portal

Providers can access Cigna's precertification portal for direct submission. Login credentials are required, and setup may take several business days for new users.

Fax and Mail Submission Details

Fax Submission

Cigna PA Fax: Use the fax number printed on the current Brineura PA form (verify with latest version) Express Scripts PA Fax: 1-866-873-8279 (for precertification intake)

Cover Sheet Tips:

  • Mark "URGENT - PEDIATRIC RARE DISEASE" if expedited review is needed
  • Include patient's full name, DOB, and Cigna member ID
  • List total number of pages being faxed
  • Request fax confirmation receipt

Mail Submission

Use certified mail with return receipt for paper submissions:

Address format:

Cigna HealthCare
Prior Authorization Department
[Verify current address on PA form]
Note: Mail submission adds 5-7 business days to processing time. Electronic submission is strongly recommended for time-sensitive cases.

Specialty Pharmacy Coordination

Express Scripts Specialty Pharmacy

Phone: 1-800-351-3606 Fax for orders: 1-800-351-3616

Setup process:

  1. Cigna PA approval must be obtained first
  2. Provider sends prescription to Express Scripts
  3. Specialty pharmacist contacts family for intake
  4. Medication is shipped to infusion center
  5. Coordination with nursing team for administration

Accredo Specialty Pharmacy

Provider Service Center: 844-516-3319

Some Cigna plans route Brineura through Accredo instead of Express Scripts. Confirm which specialty pharmacy your plan requires before prescription submission.

Key coordination steps:

  • Verify insurance benefits and PA status
  • Schedule infusion appointments
  • Coordinate with ICV device monitoring team
  • Manage refill timing (every 14 days for Brineura)

Key Contact Numbers and Support

Member Services

  • General Cigna Customer Service: Number on your ID card
  • 24-Hour Health Information Line: 1-800-244-6224
  • Specialty Pharmacy Services: 1-800-351-3606

Provider Services

  • Prior Authorization Inquiries: 1-800-882-4462
  • Expedited Appeals: Request through provider line above
  • Case Management: Available through main provider number

What to Ask When You Call:

For Members:

  • "What's my plan's specialty pharmacy for Brineura?"
  • "Is there a step therapy requirement I need to complete first?"
  • "What's the status of PA request [reference number]?"

For Providers:

  • "I need to request an expedited PA review for a pediatric CLN2 patient"
  • "Can I schedule a peer-to-peer review with your medical director?"
  • "What additional documentation do you need for this denial?"

Texas Appeals and External Review

Internal Appeals Process

Timeline: File within 180 days of denial Forms: Cigna Customer Appeal Request Decision timeframe: 30 days for medical necessity appeals

Required elements:

  • Copy of denial letter with claim/reference number
  • Updated medical necessity letter from specialist
  • Additional clinical documentation
  • Peer-reviewed literature supporting Brineura for CLN2

Texas External Review (IRO)

After exhausting internal appeals, Texas residents can request independent external review through the Texas Department of Insurance (TDI).

Key requirements:

  • Must be for medical necessity denial
  • Request within 4 months of final internal denial
  • Use TDI IRO request forms
  • Cigna pays for the review if you win

TDI Contact Information:

  • Consumer Help Line: 1-800-252-3439
  • IRO Information: 1-866-554-4926
  • Online forms: Available at TDI website

Timeline: IRO decision within 20 days (5 days for urgent cases)

Important: ERISA self-funded employer plans follow federal appeal rules, not Texas state processes. Verify your plan type before filing.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Brineura requests PA form submission Cigna Policy
Age Requirement Patient must be ≥3 years old Medical records FDA labeling
Specialist Prescription Must be prescribed by neurologist/geneticist Provider credentials Cigna PA form
CLN2 Confirmation Genetic and/or enzyme testing required Lab reports Cigna criteria
Approved Facility Infusions at certified center only Site documentation Administration requirements
Appeal Deadline 180 days from denial Denial letter Texas Insurance Code

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Diagnosis not confirmed" Submit genetic testing results TPP1 mutation analysis, enzyme levels
"Age requirement not met" Provide birth certificate/records Medical records showing age ≥3 years
"Not prescribed by specialist" Get referral to pediatric neurologist Specialist credentials and letter
"Facility not approved" Identify certified infusion center Site accreditation documentation
"Lack of medical necessity" Comprehensive appeal with literature Clinical trials, FDA labeling, guidelines

When to Escalate

Contact these resources if you're facing continued denials or delays:

Texas Department of Insurance

  • File complaints about unfair claim handling
  • Request assistance with external review process
  • Phone: 1-800-252-3439

Office of Public Insurance Counsel (OPIC)

  • Consumer advocacy for insurance issues
  • Help line: 1-877-611-6742

Disability Rights Texas

  • Legal advocacy for pediatric rare diseases
  • Assistance with Medicaid appeals and fair hearings

Update Cadence

Healthcare coverage requirements change frequently. Check for updates:

Monthly: Verify your plan's formulary status for Brineura Quarterly: Review Cigna's coverage policy for any criteria changes Annually: Confirm specialty pharmacy requirements and contact numbers As needed: Check TDI website for new appeal forms or process changes

Counterforce Health helps families navigate these complex approval processes by turning insurance denials into targeted, evidence-backed appeals. Our platform ingests denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to each payer's own rules. Visit CounterforceHealth.org to learn how we can help streamline your Brineura approval process.

Frequently Asked Questions

How long does Cigna PA take for Brineura in Texas? Standard review takes up to 72 hours from receipt of complete information. Complex cases may take 7-14 business days. Expedited review is available for urgent cases within 24-72 hours.

What if Brineura is non-formulary on my plan? Request a formulary exception using Cigna's exception process. Your specialist must certify that formulary alternatives are inappropriate or have failed.

Can I request an expedited appeal? Yes, for urgent cases where delay would jeopardize health. Have your provider call 1-800-882-4462 and explicitly request "expedited medical necessity appeal."

Does step therapy apply if we've failed treatments outside Texas? Yes, document all prior treatment failures regardless of where they occurred. Include medical records from previous providers showing ineffectiveness or adverse reactions.

What happens if Cigna denies our appeal? You can request external review through Texas Department of Insurance within 4 months of final denial. The independent review organization's decision is binding on Cigna.

From our advocates: We've seen families successfully overturn Brineura denials by focusing on the irreversible nature of CLN2 progression. One effective approach combines current CLN2 scale scores with projected decline timelines, demonstrating that delays in treatment result in permanent, preventable disability. This composite experience shows the importance of emphasizing time-sensitivity in appeals.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Coverage policies vary by plan and change over time. Always verify current requirements with your insurer and consult your healthcare provider for medical decisions. For personalized assistance with insurance appeals, consider consulting CounterforceHealth.org or contacting Texas consumer advocacy resources listed above.

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