By Counterforce Health Team in Evkeeza (evinacumab-dgnb) —

Getting Evkeeza (Evinacumab-dgnb) Covered by Cigna in Michigan: Prior Authorization, Appeals, and Cost Assistance

Answer Box: Fast Track to Evkeeza Coverage in Michigan

To get Evkeeza (evinacumab-dgnb) covered by Cigna in Michigan: Your doctor must submit prior authorization with confirmed HoFH diagnosis (genetic testing or clinical criteria), documentation of failed therapies (statin, ezetimibe, PCSK9 inhibitor), and recent LDL-C levels. Submit through Cigna's provider portal or Express Scripts/Accredo specialty pharmacy. Standard review takes 7 days; expedited available in 72 hours. If denied, file internal appeal within 180 days, then external review with Michigan DIFS within 127 days. Commercial insurance patients may qualify for up to $25,000 annual copay assistance through myRARE Patient Support Program.

First step today: Contact your prescribing physician to begin gathering HoFH diagnostic evidence and prior therapy documentation.

Table of Contents

  1. What Drives Evkeeza Costs with Cigna
  2. Benefit Investigation: What to Ask
  3. Assistance Options: Manufacturer and Foundation Programs
  4. Tiering Exceptions: When and How to Request
  5. Pharmacy Choice and Coordination
  6. Appeals on Cost Grounds
  7. Renewal Budgeting and Planning
  8. Conversation Scripts
  9. Michigan-Specific Appeals Process
  10. Common Denial Reasons and Solutions
  11. FAQ

What Drives Evkeeza Costs with Cigna

Evkeeza (evinacumab-dgnb) carries an average wholesale acquisition cost of approximately $450,000 annually, making it one of the most expensive specialty medications on the market. With Cigna, several factors determine your out-of-pocket costs:

Formulary Tier Placement: Cigna places Evkeeza on Tier 4 (Specialty Medications), which typically involves the highest cost-sharing—often 20-50% coinsurance rather than a fixed copay. Your exact percentage depends on your specific plan design.

Prior Authorization Requirements: All Evkeeza prescriptions require prior authorization through Cigna's Express Scripts specialty pharmacy network. This mandatory step can delay access but doesn't directly affect cost once approved.

Quantity Limits: Coverage is restricted to monthly dosing (typically 1-2 vials per 28 days depending on weight-based dosing), preventing stockpiling but ensuring appropriate use.

Note: Michigan residents with commercial Cigna plans are subject to state-mandated out-of-pocket maximums, which cap annual prescription drug costs. Review your plan's summary of benefits for your specific limit.

Benefit Investigation: What to Ask

Before starting the prior authorization process, gather key information about your Cigna coverage:

Call Member Services (number on your ID card) and ask:

  • What is my specialty drug coinsurance percentage for Tier 4 medications?
  • What is my annual out-of-pocket maximum for prescription drugs?
  • Do I need to use Express Scripts/Accredo specialty pharmacy?
  • Is there a copay accumulator program that affects manufacturer assistance?

Document Everything: Record the representative's name, date, and reference number for your call. Request written confirmation of coverage details via your member portal.

Key Information to Record:

  • Plan type (commercial, Medicare Advantage, etc.)
  • Deductible status and amount remaining
  • Specialty pharmacy network requirements
  • Prior authorization status and timeline

Assistance Options: Manufacturer and Foundation Programs

MyRARE Patient Support Program: Regeneron offers comprehensive support through their myRARE program for Evkeeza patients. Commercial insurance patients may receive up to $25,000 annually toward out-of-pocket costs.

Eligibility Requirements:

  • Commercial (private) insurance coverage
  • Valid Evkeeza prescription
  • Income verification (varies by program)
  • Not eligible for government insurance (Medicare, Medicaid)

To Enroll: Call 1-877-EVKEEZA (1-877-385-3392) or work with your healthcare provider to complete enrollment forms. The program also provides insurance verification, prior authorization support, and appeals assistance.

Foundation Grants: Several organizations offer assistance for rare disease medications:

  • HealthWell Foundation: Periodically opens grants for hypercholesterolemia patients
  • Patient Advocate Foundation: Provides copay relief and insurance navigation
  • PAN Foundation: Offers disease-specific funds when available
Important: Foundation grants have limited funding and may close without notice. Apply early and maintain current applications.

For patients facing coverage challenges, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeal processes by analyzing denial letters and crafting point-by-point rebuttals aligned with payer policies.

Tiering Exceptions: When and How to Request

If Evkeeza's Tier 4 cost-sharing creates financial hardship, you may request a formulary exception to lower your costs.

When to Request:

  • Tier 4 coinsurance exceeds your financial capacity
  • Lower-tier alternatives have failed or are contraindicated
  • Clinical evidence supports Evkeeza as the most appropriate therapy

Required Documentation: Your physician must certify that:

  • You've tried formulary alternatives (or they're medically inappropriate)
  • These alternatives were ineffective or detrimental
  • Evkeeza is medically necessary for your specific condition

Process: Your doctor submits a formulary exception request through Cigna's provider portal or by fax. Standard review takes 2 business days; expedited review (for urgent situations) takes 24 hours.

Pharmacy Choice and Coordination

Specialty Pharmacy Requirement: Cigna typically requires Evkeeza to be dispensed through Express Scripts' specialty pharmacy network, commonly Accredo.

Coordination Tips:

  • Confirm your specialty pharmacy before starting prior authorization
  • Ensure your clinic coordinates with the specialty pharmacy for delivery scheduling
  • Verify infusion site logistics (office, infusion center, or home administration)
  • Coordinate insurance approvals with infusion scheduling

Site of Care Considerations: Evkeeza requires IV administration every 4 weeks. Discuss with your provider whether treatment will occur in their office, an infusion center, or potentially at home through specialized nursing services.

Appeals on Cost Grounds

If Cigna denies coverage or imposes excessive cost-sharing, you have strong appeal rights in Michigan.

Cost-Related Appeal Grounds:

  • Medical necessity (drug is essential for your condition)
  • Lack of therapeutic alternatives on lower tiers
  • Prior authorization criteria met but denied
  • Incorrect tier placement

Documentation Needed:

  • Detailed medical necessity letter from your physician
  • Evidence of failed lower-tier alternatives
  • Clinical guidelines supporting Evkeeza use
  • Financial hardship documentation (if relevant)

Renewal Budgeting and Planning

Annual Considerations: Cigna typically approves Evkeeza for 12-month periods, requiring renewal documentation.

What Can Change:

  • Formulary tier placement (reviewed annually)
  • Prior authorization criteria updates
  • Cost-sharing percentages (with plan renewals)
  • Specialty pharmacy network changes

Planning Tips:

  • Start renewal process 60-90 days before expiration
  • Budget for potential cost-sharing changes
  • Maintain documentation of ongoing medical necessity
  • Review manufacturer assistance program renewals

Conversation Scripts

Calling Cigna Member Services: "Hi, I need to understand my coverage for Evkeeza, spelled E-V-K-E-E-Z-A. It's a specialty medication for homozygous familial hypercholesterolemia. Can you tell me the prior authorization status, formulary tier, and my expected cost-sharing?"

Clinic Staff Requesting Peer-to-Peer: "We're requesting a peer-to-peer review for Evkeeza prior authorization denial. The patient has confirmed HoFH with genetic testing and has failed maximum statin therapy, ezetimibe, and PCSK9 inhibitor. When can we schedule the clinical review?"

Michigan-Specific Appeals Process

Michigan provides robust appeal rights under the Patient's Right to Independent Review Act.

Internal Appeals: You have 180 days from denial to file with Cigna. Submit through your member portal or by mail/fax to the address on your denial letter.

External Review: After exhausting internal appeals, you have 127 days to file for external review with Michigan's Department of Insurance and Financial Services (DIFS).

DIFS External Review Process:

  • Submit online or paper form to DIFS
  • Standard review: 60 days maximum (often faster)
  • Expedited review: 72 hours (requires physician urgency letter)
  • Decision is binding on Cigna

Contact DIFS: Call 877-999-6442 for forms and guidance, or visit their website for the External Review Request form.

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
HoFH diagnosis not confirmed Submit genetic testing or clinical criteria evidence Genetic test results or lipid specialist evaluation
Insufficient prior therapy trials Document failed treatments with dates and outcomes Medical records showing statin, ezetimibe, PCSK9i trials
Missing recent LDL-C levels Provide current lipid panel Lab results within 3-6 months
Age restriction (under 5 years) Confirm patient age meets FDA approval Birth certificate or medical records
Not prescribed by specialist Obtain lipid specialist consultation Referral or co-management documentation

FAQ

How long does Cigna prior authorization take for Evkeeza in Michigan? Standard review takes 7 business days once all documentation is submitted. Expedited review is available within 72 hours for urgent cases.

What if Evkeeza is non-formulary on my Cigna plan? Request a formulary exception with medical necessity documentation. Your physician must certify that formulary alternatives have failed or are inappropriate.

Can I request an expedited appeal in Michigan? Yes. Michigan offers expedited external review within 72 hours if your physician certifies that delay would seriously jeopardize your health.

Does step therapy apply if I've tried therapies outside Michigan? Yes. Document all prior therapy trials regardless of where they occurred. Out-of-state medical records are acceptable evidence.

What's the difference between internal and external appeals? Internal appeals are reviewed by Cigna staff. External appeals in Michigan are reviewed by independent medical experts through DIFS and are binding on Cigna.

How much will I pay out-of-pocket with commercial Cigna coverage? This varies by plan, but Tier 4 specialty medications typically have 20-50% coinsurance. With manufacturer assistance, eligible patients may pay significantly less.

This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance company for specific coverage decisions. For official Michigan insurance appeal information, contact the Department of Insurance and Financial Services at 877-999-6442.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters, plan policies, and clinical notes to identify denial reasons and draft point-by-point rebuttals aligned with payer requirements, making the appeals process more efficient and successful.

Sources & Further Reading

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