By Counterforce Health Team in Gattex (teduglutide) —

Getting Gattex (Teduglutide) Covered by Cigna in Pennsylvania: Forms, Appeals, and Cost-Saving Strategies

Answer Box: Fast Track to Approval

Cigna requires prior authorization for Gattex (teduglutide) in Pennsylvania. Your gastroenterologist must document short bowel syndrome with parenteral nutrition dependency, failed enteral strategies, and ongoing monitoring. If denied, Pennsylvania's external review program has a 50% overturn rate. First step today: Have your prescriber complete Cigna's PA form with detailed PN logs, surgical records, and specialist attestation. Submit via Express Scripts or Cigna member portal within 72 hours for standard review, 24 hours for urgent cases.

Table of Contents

  1. What Drives Gattex Costs with Cigna
  2. Benefit Investigation: What to Ask
  3. Prior Authorization Requirements
  4. Assistance Options
  5. Formulary Exception Process
  6. Pharmacy Choice and Coordination
  7. Appeals Process in Pennsylvania
  8. Annual Renewal Planning
  9. Conversation Scripts
  10. FAQ

What Drives Gattex Costs with Cigna

Gattex (teduglutide) is classified as a specialty tier medication under Cigna plans, typically requiring the highest level of cost-sharing. The drug's wholesale acquisition cost reaches approximately $46,893 per 30-vial kit, making it one of the most expensive GI medications.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all plans Cigna member portal Cigna PA Policy
Formulary Tier Specialty Tier (highest copay) Plan formulary document Cigna Formulary
Step Therapy May apply to new patients PA determination Cigna Policy
Quantity Limits Based on FDA dosing PA review Express Scripts
Site of Care Specialty pharmacy required Accredo coordination Accredo

Key cost drivers include:

  • Benefit design: Most Cigna plans place Gattex on the specialty tier with 25-33% coinsurance rather than fixed copays
  • Prior authorization complexity: Extensive documentation requirements can delay approval
  • Specialty pharmacy mandates: Must use Accredo or approved specialty pharmacy
  • Annual deductibles: High-deductible plans require meeting full deductible before coverage begins

Benefit Investigation: What to Ask

Before starting the PA process, gather specific benefit information from Cigna:

Call Cigna Customer Service (number on your insurance card) and ask:

  • "What's my specialty drug coinsurance percentage for Gattex?"
  • "What's my annual out-of-pocket maximum for specialty drugs?"
  • "Do I need to use Accredo, or are other specialty pharmacies covered?"
  • "Is there a quantity limit per fill or per month?"
  • "What's the specific PA form number for Gattex?"

Information to record:

  • Policy/group number and member ID
  • Specialty drug benefit details
  • Deductible remaining
  • Prior authorization fax number
  • Accredo coordination requirements
Tip: Ask for a reference number for your call and the representative's name. Benefit information can vary, and having documentation helps if details change.

Prior Authorization Requirements

Cigna's PA policy for Gattex requires comprehensive documentation of medical necessity.

Step-by-Step: Fastest Path to Approval

  1. Gather Documentation (Patient/Clinic)
    • Surgical reports showing bowel resection length
    • 30-day parenteral nutrition logs with volumes
    • Failed enteral feeding attempts
    • Current weight, BMI, and nutritional labs
  2. Complete PA Form (Prescriber)
    • Use Cigna's gastroenterology PA form
    • Include ICD-10 codes (K91.2 for SBS)
    • Document specialist consultation requirement
    • Timeline: Same day completion recommended
  3. Submit via Portal (Clinic Staff)
    • Express Scripts PA portal or CoverMyMeds
    • Include all supporting documentation
    • Request expedited review if clinically urgent
    • Timeline: Submit within 24 hours
  4. Follow Up (Patient/Clinic)
    • Standard review: 72 hours
    • Expedited review: 24 hours
    • Check status via member portal
    • Timeline: Daily status checks

Clinician Corner: Medical Necessity Letter Checklist

Your gastroenterologist's letter should include:

Problem Statement:

  • Short bowel syndrome diagnosis with specific cause
  • Remaining bowel length (if known from surgical reports)
  • Current parenteral nutrition dependency

Prior Treatments:

  • Enteral feeding attempts and outcomes
  • Nutritional optimization strategies tried
  • Medications used (PPIs, antidiarrheals, etc.)

Clinical Rationale:

  • FDA-approved indication for SBS with PN dependency
  • Expected reduction in parenteral nutrition requirements
  • Quality of life improvements anticipated

Monitoring Plan:

  • Regular assessment of PN needs
  • Safety monitoring for injection site reactions
  • Periodic nutritional status evaluation

Assistance Options

Multiple programs can reduce your out-of-pocket costs for Gattex:

Manufacturer Support

Takeda Patient Assistance Program offers significant savings:

  • Copay Card: May reduce costs to $0 for commercial insurance patients
  • Eligibility: Commercial insurance required (no Medicare/Medicaid)
  • Application: Call 1-866-888-0660 or complete Gattex Start Form
  • Income limits: None disclosed for copay assistance

Help At Hand Program for uninsured patients:

  • Free medication for qualifying patients
  • Income-based eligibility criteria apply
  • Application through helpathandpap.com

Foundation Grants

Several patient assistance foundations provide grants for specialty medications:

  • HealthWell Foundation
  • Patient Access Network (PAN) Foundation
  • Good Days (formerly Chronic Disease Fund)
  • Assistance Fund
Note: Foundation funding availability changes frequently. Apply to multiple programs simultaneously for best results.

Formulary Exception Process

If Gattex is non-formulary or subject to restrictive step therapy, you can request exceptions through Cigna's formulary exception process.

When to Request Exceptions

  • Non-formulary status: Drug not covered under your specific plan
  • Step therapy requirements: Must try other medications first
  • Quantity limits: Prescribed dose exceeds plan limits
  • Site of care restrictions: Coverage limited to specific pharmacies

Documentation Requirements

Your prescriber must provide:

  • Clinical rationale for why preferred alternatives aren't appropriate
  • Evidence of contraindications to step therapy medications
  • Previous treatment failures with specific dates and outcomes
  • Medical necessity for higher quantities or different pharmacy

Timeline: Cigna must respond within 72 hours (24 hours for urgent requests).

Pharmacy Choice and Coordination

Cigna typically requires specialty medications like Gattex to be filled through Accredo Specialty Pharmacy.

Accredo Coordination Tips

  • Enrollment: Your prescriber initiates the referral to Accredo
  • Delivery: Free overnight shipping to your home or clinic
  • Refills: Automatic coordination with 7-day advance notice
  • Clinical support: Dedicated pharmacists for injection training

Alternative pharmacies may be covered with prior approval:

  • Submit exception request if you prefer a different specialty pharmacy
  • Include clinical rationale (geographic access, established relationship)
  • Timeline: 72-hour review process

Insurance Coordination

Accredo works directly with Cigna on:

  • Prior authorization status verification
  • Copay assistance program enrollment
  • Appeal submissions if needed
  • Benefit investigation and cost estimates

Appeals Process in Pennsylvania

Pennsylvania has one of the strongest patient appeal systems in the country, with a 50% success rate for external reviews in 2024.

Internal Appeals (Required First Step)

Level 1 - Standard Appeal:

  • Timeline: File within 180 days of denial
  • Review period: 30 days for standard, 72 hours for urgent
  • Documentation: Submit additional clinical evidence
  • Outcome: Approval, denial, or request for more information

Level 2 - Second Internal Review:

  • Timeline: File within 60 days of Level 1 denial
  • Review period: 30 days for standard, 72 hours for urgent
  • Process: Different reviewers than Level 1
  • Requirement: Must complete before external review

Pennsylvania External Review Program

After exhausting internal appeals, you can request an Independent External Review through the Pennsylvania Insurance Department.

Key advantages:

  • Success rate: 50% of appeals overturned in 2024
  • Cost: Free to patients
  • Timeline: 45 days for standard review, 72 hours for urgent
  • Authority: IRO decision is binding on Cigna

How to file:

  1. Obtain Final Adverse Determination letter from Cigna
  2. Submit request within 4 months via PA Insurance Department portal
  3. Provide documentation supporting medical necessity
  4. Await IRO assignment and decision

When dealing with insurance coverage challenges, platforms like Counterforce Health can help streamline the appeals process by analyzing denial letters and generating evidence-backed responses tailored to your specific payer's requirements.

When to Escalate

Contact the Pennsylvania Insurance Department if:

  • Cigna fails to meet review timelines
  • You suspect improper denial practices
  • Internal appeals process seems flawed

Contact: Pennsylvania Insurance Department Consumer Services Phone: (verify current number on pa.gov) Online: Consumer complaint portal

Annual Renewal Planning

Plan ahead for annual changes that affect Gattex coverage:

What Can Change Annually

  • Formulary status: Drug may move tiers or become non-formulary
  • Prior authorization requirements: Criteria may become more restrictive
  • Copay amounts: Specialty tier percentages can increase
  • Pharmacy networks: Accredo relationship may change

Renewal Reminders

October-November: Review next year's formulary documents December: Complete any required PA renewals January: Verify coverage is active and pharmacy access maintained Throughout year: Monitor for mid-year formulary changes

Documentation to maintain:

  • Current PA approval letters
  • Clinical response documentation
  • Parenteral nutrition logs
  • Specialist consultation notes

Conversation Scripts

Patient Script for Cigna Customer Service

"Hi, I'm calling about prior authorization for Gattex, spelled G-A-T-T-E-X, for short bowel syndrome. My member ID is [number]. Can you tell me:

  • What PA form my doctor needs to complete?
  • What's the fax number for submissions?
  • How long does review typically take?
  • What's my specialty drug coinsurance percentage?
  • Do I need to use Accredo pharmacy?"

Clinic Script for Peer-to-Peer Review

"I'm requesting a peer-to-peer review for Gattex denial. The patient has documented short bowel syndrome with [X cm] remaining small bowel, requires [X liters] parenteral nutrition daily, and has failed enteral optimization attempts. This meets FDA-approved indications and your own PA criteria. When can we schedule the clinical review?"

Email Template for Documentation Requests

"Dear [Provider],

I need the following documentation for my Gattex prior authorization appeal:

  • Surgical reports showing bowel resection details
  • 30-day parenteral nutrition logs
  • Failed enteral feeding attempt records
  • Current nutritional labs and weight trends

Please provide these within [timeframe] to support my coverage request. Thank you."

FAQ

How long does Cigna PA take for Gattex in Pennsylvania? Standard review is 72 hours, expedited review is 24 hours. If urgent medical need exists, request expedited processing.

What if Gattex is non-formulary on my Cigna plan? Request a formulary exception with clinical documentation. Your prescriber must show medical necessity and why formulary alternatives aren't appropriate.

Can I request an expedited appeal in Pennsylvania? Yes, if there's risk to your health. Both internal appeals and external reviews offer expedited timelines (72 hours vs. 30-45 days).

Does step therapy apply if I've tried similar medications outside Pennsylvania? Yes, document all previous treatments regardless of where they occurred. This evidence supports your exception request.

What's the cost difference between Accredo and other pharmacies? Accredo is typically required for specialty drugs and offers additional clinical support. Using non-preferred pharmacies may result in higher copays or no coverage.

How often do I need PA renewal for Gattex? Typically annually, but Cigna may require periodic reviews (every 6 months) to assess continued medical necessity and parenteral nutrition reduction.

What happens if my appeal is denied in Pennsylvania? After exhausting internal appeals, you can file for external review through the PA Insurance Department. This independent review has a 50% success rate.

Can I get help with the appeals process? Yes, Counterforce Health specializes in turning insurance denials into targeted appeals, and Pennsylvania offers free consumer assistance through the Insurance Department.

From our advocates: We've seen many Gattex approvals succeed when families provide detailed parenteral nutrition logs showing specific volumes and frequencies over 30 days, rather than general statements about PN dependency. The more precise your documentation, the stronger your case becomes. This approach has helped numerous patients demonstrate clear medical necessity to their reviewers.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage policies and procedures may vary by plan and change over time. Always verify current requirements with your insurance provider and consult your healthcare team for medical decisions. For personalized assistance with insurance appeals in Pennsylvania, contact the Pennsylvania Insurance Department Consumer Services.

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