By Counterforce Health Team in Tagrisso (osimertinib) —

Getting Tagrisso (Osimertinib) Covered by Cigna in Illinois: Complete PA Guide with Forms and Appeal Templates

Answer Box: Getting Tagrisso (Osimertinib) Covered by Cigna in Illinois

Cigna requires prior authorization for Tagrisso (osimertinib) with documented EGFR mutation testing and oncology management. Illinois banned step therapy in 2025 for state-regulated plans, but ERISA plans may still require it. If denied, you have 4 months to request external review through the Illinois Department of Insurance. First step: Have your oncologist submit PA documentation including EGFR mutation results and clinical rationale through Express Scripts or Accredo specialty pharmacy portals.

Table of Contents

  1. Why Illinois State Rules Matter for Cigna Coverage
  2. Cigna's Prior Authorization Requirements
  3. Turnaround Standards and Timelines
  4. Step Therapy Protections in Illinois
  5. Continuity of Care During Appeals
  6. External Review and Complaint Process
  7. Practical Scripts and Templates
  8. ERISA Plan Limitations
  9. Quick Reference Guide

Why Illinois State Rules Matter for Cigna Coverage

Illinois has some of the strongest patient protection laws in the country for specialty drug coverage. These state regulations directly impact how Cigna processes Tagrisso (osimertinib) prior authorization requests, even though Cigna operates nationally.

Key Illinois Protections:

  • Step therapy ban (effective January 1, 2025) for all state-regulated plans
  • Expedited appeal timelines (24-72 hours for urgent cases)
  • Automatic external review for medical necessity denials
  • Strong consumer assistance through the Illinois Department of Insurance

However, these protections have important limitations. If your Cigna plan is self-insured through your employer (ERISA plan), Illinois state laws don't apply—only federal regulations govern your coverage.

Tip: Check your insurance card or member portal. If it says "insured by Cigna" or mentions state regulation, Illinois laws apply. If it says "administered by Cigna" for a self-funded employer plan, you're under federal rules only.

Cigna's Prior Authorization Requirements

Cigna manages Tagrisso through Express Scripts and Accredo specialty pharmacies. The prior authorization process requires specific clinical documentation regardless of whether you're in Illinois.

Coverage at a Glance

Requirement What It Means Where to Find It Source
PA Required Yes, for all Tagrisso prescriptions Cigna formulary Cigna Policy
EGFR Testing Documented positive mutation required Lab report in medical records FDA Label Requirements
Age Requirement 18+ years Medical records Cigna Policy
Diagnosis Advanced/metastatic NSCLC ICD-10 documentation Cigna Policy
Specialty Pharmacy Express Scripts or Accredo Check member portal Plan-specific

Required Documentation

Your oncologist must submit:

  1. EGFR Mutation Testing Results
    • Positive for qualifying mutations (exon 19 deletion, L858R, T790M, etc.)
    • From FDA-approved or CLIA-certified laboratory
    • Include test date and methodology
  2. Clinical Assessment
    • Confirmed advanced or metastatic NSCLC diagnosis
    • Patient age verification (18+)
    • Current performance status and treatment goals
  3. Prior Therapy Documentation (if applicable)
    • For T790M-positive disease: progression on prior EGFR TKI
    • Documented failure, intolerance, or contraindications to alternatives
  4. Letter of Medical Necessity
    • Clinical rationale for Tagrisso specifically
    • References to NCCN or ASCO guidelines
    • Expected treatment duration and monitoring plan

Turnaround Standards and Timelines

Illinois law sets strict timelines for Cigna's review process, though federal plans may follow different schedules.

Standard Review Process

  • Initial PA Decision: 72 hours after complete submission
  • Renewal Requests: Submit 4-6 weeks before expiration
  • Incomplete Submissions: Cigna has 24 hours to notify of missing information

Expedited Reviews

For urgent medical situations:

  • Decision Timeline: 24 hours after receiving all documentation
  • Eligibility: Treatment delay would seriously jeopardize health
  • Request Process: Provider must certify urgency in submission
Note: Illinois residents can request expedited internal appeals and external reviews simultaneously for urgent cases.

Step Therapy Protections in Illinois

Illinois banned step therapy (fail-first protocols) for all state-regulated health plans effective January 1, 2025. This means Cigna cannot require you to try cheaper alternatives before covering Tagrisso—if your plan falls under Illinois jurisdiction.

Medical Exception Criteria (ERISA Plans)

For self-insured employer plans still subject to step therapy:

Automatic Exceptions:

  • Documented EGFR mutation requiring targeted therapy
  • Prior failure or intolerance to required alternatives
  • Clinical contraindications to step therapy drugs
  • Current stability on requested medication

Documentation Requirements:

  • EGFR mutation test results
  • Treatment history with outcomes
  • Physician attestation of medical necessity
  • Supporting clinical literature references

The Illinois Department of Insurance can help determine if step therapy protections apply to your specific plan. Contact their consumer hotline at 877-527-9431.

Continuity of Care During Appeals

Illinois law provides several protections to ensure you don't lose access to Tagrisso during the appeals process.

Transition Coverage:

  • 30-day supply while PA is processed
  • Continued coverage during internal appeals
  • Bridge therapy options for urgent cases

Renewal Protections:

  • Grace period for late renewals
  • Temporary coverage during review
  • Expedited processing for ongoing therapy

If you're currently stable on Tagrisso and face a coverage disruption, contact the Illinois Attorney General's Health Care Helpline for immediate assistance.

External Review and Complaint Process

When Cigna denies your Tagrisso coverage, Illinois provides robust appeal options through independent medical review.

Appeals Playbook for Cigna in Illinois

Appeal Level Timeline How to File Required Documents
Internal Appeal 15 business days Cigna member portal or written request Denial letter, medical records
Expedited Internal 24 hours Mark "urgent" on submission Provider urgency certification
External Review 4 months to request Illinois DOI form Final denial, clinical documentation
Expedited External 72 hours Check "expedited" box Urgency certification required

Step-by-Step External Review Process

  1. File Within Deadline: You have 4 months from final denial date
  2. Complete DOI Form: Use official external review form
  3. Gather Documentation:
    • Final denial letter from Cigna
    • All medical records supporting Tagrisso need
    • Provider letters explaining medical necessity
  4. Submit to DOI: Mail or fax completed package
  5. Independent Review: Board-certified oncologist reviews case
  6. Binding Decision: 5 business days after reviewer receives records

Automatic External Review (2025 Update): Medical necessity denials are now automatically forwarded for external review unless you opt out.

From Our Advocates: "We've seen several Illinois patients successfully overturn Tagrisso denials by including comprehensive EGFR mutation documentation and NCCN guideline references in their external review submissions. The key is providing the independent reviewer with clear evidence that Tagrisso is the appropriate first-line therapy for their specific mutation type."

Practical Scripts and Templates

Patient Phone Script for Cigna

"Hi, I'm calling about a prior authorization denial for Tagrisso, generic name osimertinib. My member ID is [number]. I have EGFR-positive lung cancer and this is the standard treatment per NCCN guidelines. Can you tell me exactly what documentation is missing and help me request an expedited review since any delay in treatment could affect my prognosis?"

Medical Necessity Letter Template

Patient: [Name], DOB: [Date], Member ID: [Number]
Diagnosis: EGFR mutation-positive non-small cell lung cancer
Requested: Tagrisso (osimertinib) 80mg daily

Clinical Rationale:
Patient has confirmed [specific EGFR mutation] documented by [lab/date]. 
Per NCCN Guidelines v.2024, osimertinib is first-line therapy for this mutation.
[Previous therapies tried, if any, with outcomes]
Alternative EGFR inhibitors are contraindicated due to [specific reasons].
Treatment delay risks disease progression and reduced survival.

Supporting Evidence:
- EGFR mutation test report attached
- Staging studies confirming advanced disease
- Performance status documentation
- NCCN Guidelines reference (Category 1 recommendation)

Prescriber: [Name, NPI, Contact]
Date: [Date]

ERISA Plan Limitations

If your Cigna coverage comes through an employer self-insured plan, Illinois state protections may not apply. These federal ERISA plans follow different rules:

Key Differences:

  • Step therapy may still be required
  • Different appeal timelines (federal standards)
  • Limited state regulatory oversight
  • Different external review processes

How to Tell: Check your insurance documents or call Cigna member services. ERISA plans typically say "administered by" rather than "insured by" Cigna.

ERISA Appeal Rights:

  • 180 days to file internal appeal
  • 60 days for external review after internal denial
  • Federal Department of Labor oversight

For ERISA plan issues, contact the U.S. Department of Labor Employee Benefits Security Administration for assistance.

Quick Reference Guide

Essential Contacts

  • Cigna Member Services: Number on your insurance card
  • Illinois Department of Insurance: 877-527-9431
  • Illinois Attorney General Health Care Helpline: 877-305-5145
  • Express Scripts/Accredo: Check member portal for current number

Key Forms and Websites

Critical Deadlines

  • Internal Appeal: 180 days from denial
  • External Review Request: 4 months from final denial
  • Expedited Reviews: Request immediately for urgent cases
  • ERISA Plans: 180 days internal, 60 days external

Frequently Asked Questions

How long does Cigna prior authorization take in Illinois? Standard PA decisions must be made within 72 hours of complete submission. Expedited reviews are completed within 24 hours for urgent medical situations.

What if Tagrisso is non-formulary on my plan? You can request a formulary exception with clinical justification. Illinois step therapy protections may help if alternatives aren't appropriate for your EGFR mutation.

Can I get temporary coverage while appealing? Yes, Illinois law provides transition coverage options during appeals. Contact the Illinois Department of Insurance for assistance with coverage gaps.

Does the Illinois step therapy ban apply to all Cigna plans? No, only state-regulated plans. Self-insured employer (ERISA) plans may still require step therapy, though medical exceptions are available.

How do I know if my EGFR testing meets Cigna's requirements? The test must be from an FDA-approved or CLIA-certified laboratory and show specific qualifying mutations. Your oncologist can confirm if your results meet criteria.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by providing evidence-backed documentation that aligns with each payer's specific requirements. Their platform streamlines the prior authorization process for complex medications like Tagrisso by identifying denial reasons and crafting targeted rebuttals with appropriate clinical evidence and procedural compliance.

If you're facing a Tagrisso denial from Cigna, Counterforce Health's tools can help ensure your appeal includes all necessary documentation—from EGFR mutation results to NCCN guideline citations—formatted according to Cigna's specific requirements and Illinois regulatory standards.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and state regulations may change. Always verify current requirements with your insurance plan and consult with your healthcare provider about treatment decisions. For personalized assistance with your specific situation, contact the Illinois Department of Insurance or consult with a qualified healthcare advocate.

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