By Counterforce Health Team in Chenodal (chenodiol) —

Getting Chenodal (Chenodiol) Covered by Cigna in Michigan: PA Forms, Appeals Process & Approval Timeline

Answer Box: Your Path to Chenodal Coverage

Chenodal (chenodiol) requires prior authorization from Cigna and is covered on most formularies for radiolucent gallstones in surgical non-candidates. To get approved in Michigan: (1) Ensure your gastroenterologist documents failed ursodiol therapy for 6+ months, (2) Submit Cigna's PA form with imaging showing radiolucent stones, and (3) Include evidence you're not a surgical candidate due to age/comorbidities. Standard review takes 2 business days; denials can be appealed through Michigan's 127-day external review process via DIFS.

First step today: Contact your prescriber to request the Cigna Prior Authorization form and gather documentation of prior ursodiol failure.

Table of Contents

  1. Plan Types & Coverage Implications
  2. Formulary Status & Tier Placement
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Process
  5. Cost-Share Considerations
  6. Submission Process & Forms
  7. Common Approval Patterns
  8. Appeals Process in Michigan
  9. FAQ
  10. Sources & Further Reading

Plan Types & Coverage Implications

Your Cigna plan type affects how you'll access Chenodal and manage the approval process:

HMO Plans: Typically require primary care physician coordination and may need referrals to gastroenterology specialists. Lower out-of-pocket costs but more restrictive networks. Prior authorization requests must go through your PCP or specialist within the network.

PPO Plans: Offer the most flexibility for specialist access without referrals, making it easier to work directly with gastroenterologists for PA submissions. Higher premiums but broader provider networks and out-of-network coverage options.

EPO Plans: Middle-ground option with no referral requirements for specialists but limited to in-network providers only. Emergency coverage only for out-of-network care.

Note: All plan types follow the same PA requirements for Chenodal, but your care coordination process may differ.

Formulary Status & Tier Placement

Chenodal is included on Cigna's 2024 formularies across multiple plan types, including standard, enhanced, and comprehensive drug lists.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Chenodal prescriptions PA form submission needed Cigna PA Policy
Step Therapy Ursodiol trial required first 6+ months documented failure Coverage Criteria
Specialist Requirement Gastroenterologist involvement Prescription or consultation Medical Policy
Age Restriction 18+ years only Patient eligibility Coverage Policy
Imaging Required Radiolucent stone confirmation Cholecystogram/ultrasound FDA Labeling

Alternative Options: If Chenodal is denied, ursodeoxycholic acid (ursodiol) remains the preferred first-line therapy for stone dissolution when appropriate.

Prior Authorization Requirements

Cigna requires comprehensive documentation for Chenodal approval. Here's what your gastroenterologist needs to provide:

Medical Necessity Criteria

Patient Must Be:

  • At least 18 years old
  • Diagnosed with radiolucent gallstones in well-opacifying gallbladder
  • Not a surgical candidate due to increased risk from systemic disease or age
  • Has tried ursodiol for at least 6 months with inadequate response, contraindications, or intolerance

Required Documentation:

  • Clinical diagnosis with ICD-10 codes
  • Imaging results (cholecystogram or ultrasound) confirming radiolucent stones
  • Evidence of surgical contraindication or high-risk status
  • Documentation of ursodiol trial and outcome
  • Treatment plan and monitoring schedule
Clinician Corner: Your medical necessity letter should address each PA criterion specifically. Include phrases like "patient is not a surgical candidate due to [specific comorbidity/age factors]" and "ursodiol therapy for [duration] resulted in [specific outcome]."

Specialty Pharmacy Process

Chenodal may be dispensed through Cigna's specialty pharmacy network, primarily Accredo Specialty Pharmacy.

Patient Enrollment Steps

  1. Initial Setup: Call Accredo at 877-826-7657 (Mon-Fri 7 AM-10 PM CST, Sat 7 AM-4 PM CST)
  2. Prescription Transfer: Your doctor can send prescriptions electronically or via fax
  3. Insurance Verification: Accredo will verify your Cigna coverage and PA status
  4. Delivery Coordination: Medications ship to your preferred address with tracking
  5. Ongoing Support: Access to specialty pharmacists for administration training and monitoring

Express Scripts Integration: For non-specialty needs, you can manage prescriptions through the myCigna app or Express Scripts portal at 800-835-3784.

Cost-Share Considerations

Your out-of-pocket costs depend on your specific Cigna plan's benefit design:

Typical Cost Structure:

  • Specialty tier medications often have higher copays or coinsurance
  • Deductible may apply before copay benefits begin
  • Annual out-of-pocket maximums provide cost protection

Savings Options to Explore:

  • Manufacturer patient assistance programs (verify current offerings with Travere Therapeutics)
  • Cigna's specialty pharmacy cost support services
  • State pharmaceutical assistance programs in Michigan
Important: This information is educational only. Contact Cigna member services at the number on your ID card for your specific cost-sharing details.

Submission Process & Forms

Step-by-Step: Fastest Path to Approval

  1. Gather Documentation (Patient/Clinic)
    • Insurance card and member ID
    • Complete medical records showing gallstone diagnosis
    • Imaging reports confirming radiolucent stones
    • Documentation of ursodiol trial and outcomes
  2. Complete PA Form (Prescriber)
  3. Submit Request (Prescriber)
    • Fax completed form with attachments
    • Alternative: Submit via Cigna provider portal
    • Timeline: Standard review within 2 business days
  4. Track Status (Patient/Clinic)
    • Follow up if no response within 72 hours
    • Expedited review available for urgent cases (24-hour turnaround)
  5. Handle Approval (Patient)
    • Coordinate with specialty pharmacy for dispensing
    • Schedule required monitoring appointments
  6. Manage Denials (Patient/Clinic)
    • Request detailed denial rationale
    • Prepare appeal documentation immediately
    • Consider peer-to-peer review request

Common Approval Patterns

Strong submissions typically include:

  • Clear documentation that surgery poses unacceptable risk
  • Specific ursodiol trial details (dose, duration, response measures)
  • Objective imaging evidence of radiolucent stone composition
  • Gastroenterologist's clinical rationale for Chenodal selection
  • Patient's functional status and treatment goals

Common Denial Reasons & Fixes

Denial Reason How to Overturn
Insufficient ursodiol trial Provide detailed prescription history and response documentation
Surgical candidacy not addressed Include specific risk factors and specialist assessment
Missing imaging confirmation Submit complete cholecystogram or ultrasound reports
Age/diagnosis criteria not met Verify patient age and gallstone type documentation

When to Consider Counterforce Health: If you're facing complex denials or need help crafting evidence-backed appeals, Counterforce Health specializes in turning insurance denials into targeted, successful appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with payer requirements.

Appeals Process in Michigan

If Cigna denies your Chenodal request, Michigan offers robust appeal protections:

Internal Appeals (First Step)

  • Timeline: 180 days from denial to file
  • Process: Submit written appeal with additional clinical evidence
  • Review: First and second-level internal reviews available
  • Expedited: 24-hour review for urgent cases

External Review (Final Step)

Michigan's Department of Insurance and Financial Services (DIFS) provides independent review:

  • Timeline: 127 days after final internal denial to request external review
  • Process: Submit DIFS External Review Request form online, email, fax, or mail
  • Review: Independent Review Organization (IRO) medical experts evaluate
  • Standard Decision: Within 60 days (often faster)
  • Expedited Decision: 72 hours with physician urgency letter
  • Binding: IRO decisions are final and enforceable

DIFS Contact: 877-999-6442 (toll-free) for questions about the appeal process.

From Our Advocates: We've seen Michigan external reviews succeed when patients provide comprehensive documentation showing why Chenodal is medically necessary despite the initial denial. The key is presenting clear evidence that surgical alternatives aren't viable and that ursodiol has truly failed or is contraindicated.

FAQ

How long does Cigna PA take in Michigan? Standard prior authorization requests are reviewed within 2 business days. Expedited reviews for urgent cases are completed within 24 hours.

What if Chenodal is non-formulary on my plan? You can request a formulary exception with medical necessity justification. The process follows similar documentation requirements as standard PA.

Can I request an expedited appeal in Michigan? Yes, if delay would seriously jeopardize your health. Your physician must provide a supporting letter explaining the urgency for 72-hour DIFS external review.

Does step therapy apply if I failed ursodiol outside Michigan? Yes, documented ursodiol failure from any location should satisfy Cigna's step therapy requirement if properly documented in your medical records.

What counts as "not a surgical candidate"? Age-related risks, significant comorbidities (cardiac, pulmonary, hepatic), or other medical conditions that substantially increase surgical morbidity/mortality risk.

How long is Chenodal approval valid? Approvals are typically valid for up to 12 months, with renewal requiring updated clinical documentation and monitoring results.

Can my doctor request a peer-to-peer review? Yes, prescribers can request direct discussion with Cigna's medical director to discuss complex cases and provide additional clinical context.

What if I'm already taking Chenodal and switch to Cigna? Continuity of care provisions may apply. Contact Cigna immediately to arrange temporary coverage while PA processing occurs.

For additional support navigating complex insurance approvals, Counterforce Health helps patients, clinicians, and pharmacies turn denials into successful appeals by providing evidence-backed documentation that meets payer-specific requirements.

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 benefits and clinical circumstances. Always consult your healthcare provider for medical guidance and contact Cigna member services for definitive coverage information. For questions about Michigan insurance regulations or external review processes, contact the Michigan Department of Insurance and Financial Services at 877-999-6442.

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