By Counterforce Health Team in Photrexa (riboflavin ophthalmic solution) —

Getting Photrexa (Riboflavin) Covered by Cigna in Florida: Complete Guide to Prior Authorization, Appeals, and Cost Savings

Answer Box: Getting Photrexa Covered by Cigna in Florida

Cigna requires prior authorization for Photrexa (riboflavin ophthalmic solution) used in corneal cross-linking for progressive keratoconus. To get coverage in Florida:

  1. Document progression: Gather serial corneal topography showing Kmax increase ≥1.0 diopter
  2. Submit PA: Use CoverMyMeds or Cigna Provider Portal with clinical notes and ICD-10 code H18.621
  3. If denied: File internal appeal within 180 days, then request external review through Florida DFS

First step today: Contact your ophthalmologist to confirm they have documented keratoconus progression and can submit the prior authorization with required clinical evidence.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before treatment CoverMyMeds or Cigna Provider Portal Cigna PA Requirements
Documented Progression Kmax increase ≥1.0 D on serial topography Your ophthalmologist's records Clinical Coverage Criteria
FDA-Approved Protocol Epithelium-off only with iLink system Treatment facility confirmation FDA Labeling
ICD-10 Code H18.621 (unstable keratoconus) PA submission form Coding Requirements
Appeal Deadline 180 days from denial Denial letter Cigna Appeals Process
External Review After internal appeal fails Florida DFS Florida Insurance Appeals

Understanding Photrexa Costs and Cigna's Benefit Design

Photrexa (riboflavin ophthalmic solution) is classified as a specialty medication under most Cigna plans, meaning it falls into the highest cost-sharing tier. The complete corneal cross-linking procedure typically costs $2,500–$4,000 per eye, including the drug, device, and facility fees.

How Cigna Structures Photrexa Coverage

Formulary Placement: Photrexa is typically placed on Cigna's specialty tier (Tier 4 or 5), requiring the highest member cost-share—usually 20-33% coinsurance rather than a flat copay. This percentage applies after you meet your deductible.

Specialty Pharmacy Requirement: Most Cigna plans require specialty medications like Photrexa to be dispensed through their specialty pharmacy network, often Express Scripts/Accredo.

Note: Unlike other tiers, you generally cannot request a cost-sharing exception to lower your out-of-pocket costs for specialty-tier medications. However, medical necessity exceptions are still possible if Photrexa is the only appropriate treatment option.

Step-by-Step: Fastest Path to Prior Authorization

1. Confirm Disease Progression (Your Ophthalmologist)

  • Required: Serial corneal topography showing Kmax increase ≥1.0 diopter
  • Timeline: Must have at least two measurements separated in time
  • Documentation: Clinical notes supporting progressive keratoconus diagnosis

2. Gather Required Clinical Information

  • ICD-10 Code: H18.621 (keratoconus, unstable)
  • Prior treatments: Document failed contact lens trials or intolerance
  • Visual acuity trends: Show functional decline
  • Treatment goals: Clear rationale for cross-linking intervention

3. Submit Prior Authorization (Prescriber)

  • Method: CoverMyMeds portal or Cigna Provider Portal
  • Timeline: Standard review typically 3-5 business days
  • Expedited option: Available for urgent cases (24-72 hours)

4. Track Your Request

  • Patient portal: Monitor status through MyCigna
  • Provider follow-up: Clinic should receive determination within 5 business days
  • Documentation: Keep copies of all submissions

Investigating Your Cigna Benefits

Before starting treatment, gather key information about your specific plan:

Questions to Ask Cigna Member Services

Call: The number on your insurance card

  1. "Is Photrexa covered under my pharmacy or medical benefits?"
  2. "What's my specialty tier cost-share percentage and annual out-of-pocket maximum?"
  3. "Do I need to use a specific specialty pharmacy?"
  4. "Is prior authorization required, and what's the typical processing time?"
  5. "Are there any step therapy requirements I need to complete first?"

Information to Record

  • Plan name and ID number
  • Specialty pharmacy network (likely Express Scripts/Accredo)
  • Prior authorization requirements
  • Your deductible status and out-of-pocket costs year-to-date

Cost Assistance and Savings Options

Glaukos Copay Savings Program

Eligibility: Commercially insured patients (excludes Medicare, Medicaid, Tricare)

  • Benefit: Up to $100 per eye (maximum $200 total)
  • Requirements: Submit completed application and EOB showing pharmaceutical copay (J2787)
  • Processing: 14-21 days after documentation submitted
  • Application: Download from Glaukos website
Important: This program covers only the pharmaceutical costs (Photrexa drug), not the physician procedure fees or facility charges.

Additional Financial Resources

While no keratoconus-specific foundations provide direct grants for Photrexa treatment, consider these options:

General Patient Assistance:

  • Contact Patient Access Network Foundation for potential support
  • Ask your ophthalmologist's office about payment plans or sliding scale fees
  • Explore clinical trials at ClinicalTrials.gov (search "keratoconus cross-linking")

Insurance Advocacy: Counterforce Health helps patients navigate insurance denials and appeals for specialty medications like Photrexa, turning denial letters into evidence-backed appeals tailored to your specific plan's requirements.

When Cigna Denies: Appeals Process in Florida

Internal Appeal (Level 1)

Timeline: Must file within 180 days of denial date How to File:

  • Complete Cigna appeal form
  • Mail to: Cigna Healthcare National Appeals Unit, PO Box 188062, Chattanooga, TN 37422
  • Or call customer service number on your ID card

Required Documentation:

  • Original denial letter or EOB
  • Physician statement of medical necessity
  • Clinical records supporting progression
  • Peer-reviewed literature supporting treatment

Processing Time: Decision within 60 days

External Review (Level 2)

If internal appeal fails, Florida law provides independent external review:

How to Request: Contact Florida Department of Financial Services Timeline: Must request within 4 months of final internal denial Cost: Free to consumers Decision: Binding on Cigna if reviewer determines treatment is medically necessary

Expedited Review: Available for urgent cases with 72-hour decision timeline

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn Required Documentation
"Lack of progression documentation" Submit serial topography with dates Kmax measurements showing ≥1.0 D increase
"Not FDA-approved protocol" Confirm epi-off technique with iLink Facility attestation of FDA-approved method
"Step therapy not completed" Document failed alternatives Contact lens trial records, intolerance notes
"Experimental/investigational" Cite FDA approval status FDA labeling, clinical guidelines
"Out-of-network facility" Request network exception Medical necessity for specific provider

Clinician Corner: Medical Necessity Letter Essentials

Key Elements for Appeals:

  1. Clear diagnosis: Progressive keratoconus with ICD-10 H18.621
  2. Objective progression: Serial topography with specific Kmax values and dates
  3. Failed alternatives: Document contact lens intolerance or inadequate vision correction
  4. Treatment rationale: Explain why cross-linking is medically necessary now
  5. FDA compliance: Confirm epithelium-off protocol with approved Photrexa formulations
  6. Guideline support: Reference American Academy of Ophthalmology or cornea society guidelines

Specialty Pharmacy Coordination

Working with Express Scripts/Accredo

Most Cigna plans require specialty medications through their contracted pharmacy:

Setup Process:

  1. Your doctor sends prescription to designated specialty pharmacy
  2. Pharmacy contacts you to arrange delivery and coordinate with treatment facility
  3. Medication ships 2-3 days before procedure date

Key Coordination Points:

  • Confirm delivery address and contact information
  • Verify procedure date with your ophthalmologist
  • Understand storage requirements (Photrexa may need refrigeration)

Planning for Annual Renewals

What Can Change Year-to-Year

  • Formulary placement: Photrexa's tier status may change
  • Prior authorization requirements: Criteria may become more or less restrictive
  • Network changes: Your ophthalmologist or treatment facility coverage
  • Cost-sharing: Deductibles and coinsurance percentages often increase

Annual Review Checklist

Each January:

  • Verify your ophthalmologist remains in-network
  • Check updated formulary for any Photrexa changes
  • Review your plan's Summary of Benefits for cost-share updates
  • Confirm specialty pharmacy network hasn't changed

Scripts for Key Conversations

Calling Cigna Member Services

"Hi, I'm calling about coverage for Photrexa, which is riboflavin ophthalmic solution used for corneal cross-linking. My member ID is [number]. I need to understand if this requires prior authorization, what my cost-share would be, and which specialty pharmacy I need to use."

Requesting Peer-to-Peer Review (Clinic Staff)

"We're requesting a peer-to-peer review for [patient name] regarding the Photrexa prior authorization denial. The treating physician is Dr. [name], a cornea specialist. We have additional clinical documentation showing clear keratoconus progression that meets your criteria. When can we schedule this review?"

Following Up on Pending Appeals

"I'm calling about my appeal for Photrexa coverage, reference number [if available]. It's been [timeframe] since I submitted my appeal on [date]. Can you provide a status update and expected decision timeline?"

FAQ: Photrexa Coverage with Cigna

How long does Cigna prior authorization take for Photrexa in Florida? Standard prior authorization typically processes within 3-5 business days. Expedited reviews for urgent cases can be completed in 24-72 hours.

What if Photrexa isn't on my Cigna formulary? You can request a formulary exception with your physician's support. The doctor must provide clinical justification for why Photrexa is medically necessary and preferred alternatives aren't suitable.

Can I request an expedited appeal if my vision is deteriorating rapidly? Yes, Cigna offers expedited appeals for urgent medical situations. Your ophthalmologist must document that delay in treatment poses a significant risk to your vision.

Does step therapy apply if I tried contact lenses in another state? Previous treatment records from other states count toward step therapy requirements. Ensure your current ophthalmologist has documentation of these prior trials.

What happens if both internal and external appeals fail? After exhausting all appeal levels, you may pay out-of-pocket and pursue reimbursement, seek treatment through a clinical trial, or explore alternative financing options.

Are there any Florida-specific insurance protections for keratoconus patients? Florida follows federal ACA requirements for essential health benefits and external review. The state also has consumer assistance through the Department of Financial Services insurance helpline: 1-877-MY-FL-CFO.

This guide provides general information about insurance coverage and appeals processes. It is not medical advice. Always consult with your ophthalmologist and insurance plan for specific guidance regarding your situation.

Need help with a Cigna denial? Counterforce Health specializes in turning insurance denials into successful appeals by analyzing your specific plan's criteria and crafting evidence-backed responses that speak directly to Cigna's coverage requirements.

Sources & Further Reading

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