By Counterforce Health Team in Translarna (ataluren) —

Getting Translarna (Ataluren) Covered by Cigna in Michigan: Complete Forms Guide and Appeals Process

Answer Box: Quick Path to Translarna Coverage

To get Translarna (ataluren) covered by Cigna in Michigan: Your doctor must submit the Michigan Prior Authorization Request Form FIS 2288 with complete clinical documentation. Cigna must respond within 15 days (or 72 hours for expedited requests). If denied, you have 180 days for internal appeals, then 127 days for external review through Michigan DIFS. Start today: Contact your prescriber to initiate the PA request and ensure all genetic testing confirms nonsense mutation DMD.

Table of Contents

  1. Verify Your Plan and Coverage
  2. Required Forms and Documentation
  3. Submission Portals and Methods
  4. Specialty Pharmacy Enrollment
  5. Support Lines and Contacts
  6. Michigan Appeals Process
  7. Common Denial Reasons and Solutions
  8. Update Schedule and Resources

Verify Your Plan and Coverage

Before starting the prior authorization process, confirm your specific Cigna plan details:

Check Your Coverage:

  • Log into your myCigna account or call the member services number on your insurance card
  • Verify Translarna's formulary status and tier placement
  • Confirm if your plan uses Cigna Pathwell Specialty (in-network only requirements)

Key Questions to Ask:

  • Is prior authorization required for Translarna?
  • What tier is Translarna on my formulary?
  • Do I need to use Accredo specialty pharmacy?
  • Are there step therapy requirements?
Note: Cigna frequently manages specialty drugs like Translarna through their Pathwell Specialty program, which may require in-network providers only.

Required Forms and Documentation

Primary Form: Michigan FIS 2288

Your prescriber must complete the Michigan Prior Authorization Request Form for Prescription Drugs (FIS 2288). This state-mandated form includes:

Required Information:

  • Patient demographics and insurance details
  • Prescriber information with NPI and license number
  • Detailed diagnosis with ICD-10 codes
  • Specific medication requested (Translarna/ataluren)
  • Dosage, frequency, and duration
  • Clinical justification for medical necessity

Supporting Documentation Checklist:

  • ✅ Genetic testing confirming nonsense mutation DMD
  • ✅ Documentation of ambulatory status
  • ✅ Prior therapy trials and outcomes
  • ✅ Current clinical assessments
  • ✅ Specialist consultation notes
  • ✅ Insurance cards (front and back copies)

Medical Necessity Letter Requirements

Your physician should include a comprehensive medical necessity letter addressing:

  1. Specific Diagnosis: Duchenne muscular dystrophy with confirmed nonsense mutation
  2. Clinical Rationale: Why Translarna is appropriate for this patient
  3. Prior Treatments: Other therapies tried and their outcomes
  4. Contraindications: Why alternatives aren't suitable
  5. Treatment Goals: Expected outcomes and monitoring plan

Submission Portals and Methods

Electronic Submission

  • Cigna Provider Portal: Most efficient method for enrolled providers
  • Express Scripts Portal: If your plan uses Express Scripts pharmacy benefits
  • Accredo Provider Portal: For specialty pharmacy coordination

Fax Submission

Submit completed forms via fax to the number specified on your plan documents. Include a cover sheet noting:

  • "URGENT: Prior Authorization Request"
  • Patient name and member ID
  • Prescriber contact information
  • Total pages being transmitted

Processing Timelines (Michigan Law)

Standard Requests: 15 days maximum Expedited Requests: 72 hours maximum Additional Information: If Cigna requests more documentation, they have 15 days (standard) or 72 hours (expedited) from receipt

Important: If Cigna fails to respond within these timeframes, Michigan law considers the prior authorization automatically approved.

Specialty Pharmacy Enrollment

Cigna typically requires specialty drugs like Translarna to be dispensed through Accredo Specialty Pharmacy.

Enrollment Process

  1. Provider Referral: Your doctor submits the Accredo Prescription & Enrollment Form
  2. Patient Onboarding: Accredo contacts you within 24-48 hours
  3. Insurance Verification: Accredo coordinates with Cigna for coverage confirmation
  4. Delivery Setup: Free home delivery arrangements made

Accredo Contact Information:

  • Providers: 844-516-3319
  • Patients: 877-826-7657
  • Fax: 888-302-1028

Transfer from Another Pharmacy

If you currently have Translarna at another pharmacy, notify Accredo during enrollment. They'll coordinate the transfer directly to ensure no therapy interruption.

Support Lines and Contacts

Cigna Member Services

Primary Contact: Number on your insurance card Available: 24/7 for urgent issues Services: Coverage verification, PA status, appeals assistance

Cigna Specialty Support

Phone: 800-351-3606 Purpose: Specialty drug list questions, Pathwell program info Hours: Business hours, Monday-Friday

Case Management

Cigna provides dedicated nurse case managers for specialty drug patients. Ask member services to connect you with specialty case management for personalized support.

What Case Managers Help With:

  • Navigating prior authorization process
  • Finding in-network providers
  • Coordinating care between specialists
  • Understanding coverage benefits

Michigan Appeals Process

If your initial prior authorization is denied, Michigan provides strong appeal rights.

Internal Appeals with Cigna

Timeline: 180 days from denial date Levels: First-level and second-level internal reviews Expedited Option: Available if delay would harm your health

How to Appeal:

  1. Submit written appeal stating why Translarna should be covered
  2. Include additional clinical evidence
  3. Request peer-to-peer review if appropriate
  4. Track all communications and deadlines

External Review with Michigan DIFS

After exhausting internal appeals, you can request external review.

Timeline: 127 days from final internal denial Process: Independent medical experts review your case Decision: Binding on Cigna if approved

Contact Michigan DIFS:

Standard Review: 60 days maximum Expedited Review: 72 hours (requires physician letter stating urgency)

Common Denial Reasons and Solutions

Denial Reason Solution Strategy Required Documentation
Not medically necessary Submit comprehensive medical necessity letter with clinical guidelines Genetic testing, specialist evaluation, treatment history
Step therapy not completed Document contraindications to required first-line therapies Allergy records, prior adverse reactions, clinical notes
Non-formulary drug Request formulary exception with medical necessity justification Comparative effectiveness data, failed alternatives
Quantity limits exceeded Provide clinical rationale for prescribed dosing Weight-based calculations, FDA labeling, specialist recommendations
Experimental/investigational Submit current regulatory status and published evidence FDA communications, peer-reviewed studies, clinical guidelines

Scripts for Common Situations

Calling Cigna Member Services: "I'm calling about prior authorization status for Translarna for my [child/family member] with Duchenne muscular dystrophy. The PA was submitted on [date] and I need to check the status and any additional requirements."

Requesting Expedited Review: "This is a request for expedited prior authorization review. The patient has Duchenne muscular dystrophy and any delay in treatment could result in irreversible muscle deterioration."

When to Get Help

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned to the plan's own rules, pulling the right citations from FDA labeling, peer-reviewed studies, and specialty guidelines. If you're facing repeated denials or complex appeals, Counterforce Health can help streamline the process and improve approval rates.

Update Schedule and Resources

Regular Updates Needed

Monthly: Check Cigna formulary updates Quarterly: Verify Pathwell Specialty drug list changes
Annually: Review plan benefits and coverage policies

Key Resources to Monitor:

FAQ

Q: How long does Cigna take to process prior authorization in Michigan? A: Michigan law requires decisions within 15 days for standard requests and 72 hours for expedited requests.

Q: What if Translarna isn't on Cigna's formulary? A: Your doctor can request a formulary exception by calling Cigna or submitting written justification for medical necessity.

Q: Can I appeal if step therapy is required? A: Yes, if you have contraindications to required first-line therapies or have previously failed them, document this in your appeal.

Q: Does Cigna cover Translarna for all DMD patients? A: Coverage typically requires confirmation of nonsense mutation DMD and ambulatory status, as these align with the drug's approved indications.

Q: What's the difference between internal and external appeals? A: Internal appeals are reviewed by Cigna; external appeals in Michigan are reviewed by independent medical experts through DIFS.

Q: How do I know if I need to use Accredo pharmacy? A: Check if your plan includes Pathwell Specialty requirements or ask Cigna member services about mandatory specialty pharmacy use.

From Our Advocates: "We've seen many Translarna approvals succeed when families work closely with their neuromuscular specialist to document the specific genetic mutation and current functional status. The key is showing medical necessity through comprehensive genetic testing and clinical assessments rather than just submitting basic prescription information."

Important: This guide provides general information about insurance processes and should not be considered medical or legal advice. Coverage decisions vary by individual plan and clinical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance.

For additional support with Michigan health insurance appeals, contact Michigan DIFS at 877-999-6442 or visit their consumer assistance webpage.

Sources & Further Reading

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