By Counterforce Health Team in Trikafta (elexacaftor/tezacaftor/ivacaftor) —

Getting Trikafta Covered by Cigna in Washington: Complete Prior Authorization and Appeals Guide

Answer Box: Fast Track to Trikafta Coverage

To get Trikafta covered by Cigna in Washington: 1) Confirm your CFTR genetic testing shows an FDA-approved mutation, 2) Have your CF specialist submit a prior authorization with baseline labs and medical necessity letter, 3) If denied, file an internal appeal within 180 days, then request external review through Washington's Independent Review Organization within 60 days. Most approvals happen at the PA stage when documentation is complete. Start with Cigna's PA form.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before dispensing Cigna provider portal Cigna PA Policy
CFTR Genotype At least one FDA-approved mutation Genetic test report FDA Label Requirements
CF Specialist Prescribed by or with CF expert Provider credentials Cigna Coverage Policy
Age Requirement 2 years or older Birth certificate/records FDA Approval Criteria
Baseline Labs Liver function tests required Recent lab results Monitoring Requirements
Specialty Pharmacy Usually through Accredo Pharmacy network Express Scripts Network

Step-by-Step: Fastest Path to Approval

1. Confirm Your Genetic Testing (Patient/Family)

What you need: CFTR genetic test showing at least one FDA-approved mutation (like F508del) Timeline: If you don't have this, request it from your CF center—results typically take 1-2 weeks Action: Contact your CF care team to ensure your genetic testing is complete and documented

2. Gather Required Documentation (CF Clinic)

What's needed:

  • Recent clinic notes with CF diagnosis
  • Pulmonary function tests (PFTs)
  • Baseline liver function tests
  • Documentation of prior therapy failures (if applicable) Timeline: 2-3 business days to compile Submit to: Your CF specialist's office for PA preparation

3. Submit Prior Authorization (CF Specialist)

Required form: Cigna PA request form Submit via: Cigna provider portal or fax to 855-840-1678 Timeline: Cigna has 5 business days to respond Include: Medical necessity letter, genetic testing, baseline labs, clinic notes

4. Track Your Request (Patient)

How: myCigna app or call member services Timeline: Decision within 5 business days of complete submission Next step: If approved, Accredo will contact you for delivery setup

5. If Denied: File Internal Appeal (Patient/Provider)

Deadline: 180 days from denial letter date Required: Appeal form, additional clinical evidence, peer-to-peer review request Timeline: 30 days for standard review, 72 hours for expedited

6. External Review (If Still Denied)

Deadline: 60 days from final internal denial Process: Washington assigns Independent Review Organization (IRO) Timeline: 20 days for decision (72 hours if expedited) Contact: Washington Insurance Commissioner

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
"Genetic testing not provided" Submit complete CFTR mutation analysis Lab report showing specific mutations
"Not medically necessary" Strengthen clinical justification Enhanced medical necessity letter, PFT trends
"Step therapy required" Request exception with clinical rationale Documentation why alternatives inappropriate
"Age requirement not met" Verify patient meets 2+ years criteria Birth certificate, current age verification
"Prescriber not qualified" Confirm CF specialist involvement Provider credentials, consultation notes
Tip: According to Cigna's policy, the most common approval barrier is incomplete genetic documentation. Ensure your CFTR testing specifically lists pathogenic mutations covered by the FDA label.

Appeals Process for Washington Residents

Internal Appeals with Cigna

  • First Level: Submit within 180 days of denial
  • Required: Appeal form, clinical documentation, prescriber letter
  • Timeline: 30 days for decision (72 hours if expedited)
  • Submit to: Cigna appeals department via member portal or mail

External Review (IRO Process)

Washington residents have strong appeal rights through the state's Independent Review Organization process:

  • Deadline: 60 days from final Cigna denial
  • Assignment: Washington automatically assigns a certified IRO
  • Your rights: 5 business days to submit additional evidence
  • Cigna's obligation: Must send all records to IRO within 3 business days
  • Decision timeline: 20 days (72 hours if expedited)
  • Binding result: If IRO approves, Cigna must cover the medication

To request external review: Contact the Washington Office of the Insurance Commissioner at 1-800-562-6900.

Medical Necessity Letter Essentials

Required Clinical Elements

Your CF specialist's medical necessity letter should include:

Patient Information:

  • Confirmed CF diagnosis with ICD-10 code
  • CFTR genetic testing results with specific mutations
  • Current age (must be 2+ years)

Clinical Justification:

  • Recent pulmonary function tests showing disease progression or severity
  • History of CF-related complications
  • Prior CFTR modulator trials and outcomes (if applicable)
  • Expected clinical benefits from Trikafta

Safety Monitoring:

  • Baseline liver function tests completed
  • Plan for ongoing monitoring per FDA requirements
  • Assessment of drug interactions
From our advocates: We've seen the strongest approvals when medical necessity letters include specific PFT trends over time and reference the patient's CFTR mutation by name. Generic letters often trigger additional review, while detailed, mutation-specific requests typically get approved faster.

When Cigna Says No: Real Appeal Strategies

Peer-to-Peer Review

Request a clinical discussion between your CF specialist and Cigna's medical director:

  • When to use: After initial denial, before formal appeal
  • How to request: Call Cigna provider line at 800-882-4462
  • Preparation: Have genetic testing, recent PFTs, and treatment history ready
  • Success factors: Emphasize mutation-specific efficacy data and lack of alternatives

Evidence That Wins Appeals

Based on successful Trikafta appeals, include:

  • Genetic documentation: Complete CFTR analysis showing FDA-approved mutations
  • Clinical progression: PFT decline or frequent exacerbations
  • Specialist support: Letter from accredited CF center physician
  • Guideline alignment: Reference CF Foundation care guidelines
  • Safety monitoring: Demonstrated ability to monitor for adverse effects

Escalation to Washington State

If Cigna's internal appeals fail:

  1. File for external review with Washington's IRO system
  2. Contact the Insurance Commissioner's consumer helpline: 1-800-562-6900
  3. Submit complaint if you believe Cigna violated state insurance laws

Companies like Counterforce Health specialize in turning insurance denials into successful appeals by analyzing the specific denial reasons and crafting evidence-backed responses that address each payer's unique requirements.

Cost Support Options

Manufacturer Programs

  • Vertex Patient Services: Financial assistance and copay support
  • Eligibility: Based on insurance status and income
  • Contact: 1-877-752-5933

Foundation Support

  • CF Foundation Compass: Insurance navigation and financial assistance
  • Services: Appeal support, emergency financial aid
  • Contact: 1-844-COMPASS (1-844-266-7277)

Washington State Programs

  • Apple Health (Medicaid): May cover Trikafta for eligible residents
  • Emergency assistance: Through Washington's patient assistance programs

Frequently Asked Questions

How long does Cigna prior authorization take in Washington? Cigna has 5 business days to respond to complete PA requests. Incomplete submissions may take longer as they request additional information.

What if Trikafta isn't on my Cigna formulary? You can request a formulary exception through Cigna's appeals process. Your CF specialist will need to provide medical necessity documentation explaining why covered alternatives aren't appropriate.

Can I get expedited approval if my health is declining? Yes. If delay could jeopardize your health, request expedited review. Cigna must respond within 72 hours for urgent requests.

Does Washington's external review cost anything? No. The IRO review process is free for patients. Washington requires insurers to pay the IRO fees.

What if I have an employer-sponsored (ERISA) plan? ERISA plans may have different appeal procedures, but many voluntarily follow state requirements. Check with your HR department or contact the Department of Labor for ERISA-specific guidance.

How often do Trikafta appeals succeed? While specific statistics aren't published, appeals with complete genetic documentation and specialist support have high success rates, especially when they address the specific denial reasons.

Can I switch to a different Cigna plan during open enrollment? Yes, but Trikafta will likely require prior authorization regardless of which Cigna plan you choose. The genetic and clinical requirements remain consistent.

What happens if the IRO denies my appeal? The IRO decision is binding on Cigna, but you may still pursue legal action or file a complaint with Washington's Insurance Commissioner if you believe laws were violated.

When navigating complex prior authorization requirements, services like Counterforce Health help patients and providers build stronger cases by identifying specific denial reasons and crafting targeted responses using the right clinical evidence and payer-specific language.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms, medical circumstances, and current policies. Always consult with your healthcare provider and insurance plan directly for personalized guidance. For assistance with insurance appeals, contact the Washington Office of the Insurance Commissioner at 1-800-562-6900.

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