By Counterforce Health Team in Cresemba (isavuconazole) —

How Long Does It Take to Get Cresemba (Isavuconazole) Approved by Cigna in North Carolina? Complete Timeline & Appeal Guide

Answer Box: Quick Start Guide

Getting Cresemba (isavuconazole) approved by Cigna in North Carolina typically takes 2-5 business days with complete documentation. For invasive aspergillosis, you'll need to try voriconazole first (step therapy) unless contraindicated. If denied, North Carolina offers external review through Smart NC with 45-day standard or 72-hour expedited timelines.

Your first step today: Have your infectious disease specialist submit a prior authorization through CoverMyMeds or the Cigna provider portal, including diagnosis confirmation, prior antifungal history, and medical necessity letter addressing step therapy requirements.

Table of Contents

  1. What Affects Cresemba Approval Timing
  2. Pre-Submission Preparation (0-2 Days)
  3. Submission to Initial Review (1-5 Days)
  4. Additional Information Requests (1-7 Days)
  5. Decision Window & Outcomes
  6. If Denied: North Carolina Appeal Process
  7. Renewal Cycles & Reauthorization
  8. Timeline Visual & Milestones
  9. Time-Saving Tips for Faster Approval

What Affects Cresemba Approval Timing

Several factors influence how quickly Cigna processes your Cresemba (isavuconazole) prior authorization in North Carolina:

Benefit Type & Plan Design

  • Commercial plans: Standard 2-5 business day review through Express Scripts
  • Medicare Advantage: May require additional documentation for medical necessity
  • Medicaid (expanding in NC): Different criteria and potentially longer review times

Clinical Complexity

Cigna's antifungal coverage policy requires specific documentation based on your condition:

Indication Step Therapy Required Typical Approval Duration
Invasive aspergillosis Yes (voriconazole first) 6 months
Invasive mucormycosis No 6 months
HIV-related fungal infections Case-by-case 3-6 months

Documentation Completeness

Complete submissions receive decisions within Cigna's standard timeline, while incomplete requests trigger information requests that can add 3-7 days.

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist

Before submitting your prior authorization, gather:

Patient Information:

  • Cigna member ID and group number
  • Current weight and age
  • Complete medication list (checking for drug interactions)

Clinical Evidence:

  • Confirmed diagnosis with ICD-10 codes:
    • Invasive aspergillosis: B44.0-B44.7
    • Invasive mucormycosis: B46.x
  • Culture results, pathology reports, or imaging studies
  • Galactomannan, beta-D-glucan, or other fungal biomarkers
  • Infectious disease specialist consultation notes

Prior Therapy Documentation (Critical for Aspergillosis):

  • Voriconazole trial details: dates, doses, duration
  • Reason for discontinuation (failure, toxicity, contraindication)
  • Laboratory results showing adverse effects (liver enzymes, drug levels)
  • Documentation of intolerance or contraindications
Tip: For invasive mucormycosis, step therapy with voriconazole is not required, potentially shortening approval time to 1-2 days with complete documentation.

Submission to Initial Review (1-5 Days)

Cigna's Review Timeline

Express Scripts, Cigna's pharmacy benefit manager, completes most coverage reviews within 2 business days of receiving complete information. However, Cigna's standard policy allows up to 5-10 business days for complex cases.

Electronic Submission Options

Fastest Routes:

  1. CoverMyMeds - Real-time decisions possible
  2. EviCore Pharmacy Drug Portal - Express Scripts integration
  3. Provider EHR systems - Direct submission capability
  4. MyAccredoPatients - For specialty pharmacy coordination

What Reviewers Check First

Cigna's clinical team immediately evaluates:

  • FDA-approved indication match
  • Age and weight requirements (oral: ≥6 years, ≥16 kg)
  • Step therapy compliance for aspergillosis
  • Infectious disease specialist involvement
  • Drug interaction screening
Note: Marking requests as "urgent" when clinically appropriate (life-threatening infection, rapid progression) can expedite review to 24-72 hours.

Additional Information Requests (1-7 Days)

Common Information Requests

If Cigna requests additional documentation, respond within 48 hours to avoid delays:

For Aspergillosis Cases:

  • More detailed voriconazole trial history
  • Specific adverse event documentation
  • Drug interaction details with current medications

For All Cases:

  • Updated culture or imaging results
  • Clarification of diagnosis codes
  • Infectious disease specialist attestation

How to Respond Quickly

  • Portal updates: Submit additional documents through the same electronic system
  • Fax submission: Use the case reference number for tracking
  • Phone follow-up: Contact the prior authorization department directly

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by identifying the specific denial basis and drafting point-by-point rebuttals aligned to each plan's own rules. Their platform can help streamline the documentation process and reduce back-and-forth with insurers.

Decision Window & Outcomes

Typical Approval Outcomes

Approved (70-80% of complete submissions):

  • Duration: Usually 6 months for invasive fungal infections
  • Quantity limits: Aligned with FDA dosing (loading dose, then maintenance)
  • Pharmacy restrictions: May require Accredo or Express Scripts specialty pharmacy

Conditional Approval:

  • Requires specific monitoring (liver function, drug levels)
  • Limited quantity pending clinical response
  • Specialist follow-up requirements

Denied - Common Reasons:

  • Step therapy not completed (aspergillosis)
  • Insufficient diagnostic evidence
  • Off-label use without strong justification
  • Missing infectious disease consultation

If Denied: North Carolina Appeal Process

North Carolina offers robust consumer protections through the Smart NC program for insurance appeals.

Cigna Internal Appeals

First-Level Appeal:

  • Deadline: 180 days from denial
  • Timeline: 30 days for standard, 72 hours for expedited
  • Requirements: Medical necessity letter addressing specific denial reasons

Second-Level Appeal:

  • Deadline: 60 days from first-level decision
  • Timeline: Similar to first level
  • Enhanced documentation: Additional clinical evidence, guidelines citations

North Carolina External Review (Smart NC)

If Cigna's internal appeals are unsuccessful, North Carolina residents can request external review through Smart NC.

Key Features:

  • Standard review: 45 days for decision
  • Expedited review: 72 hours for urgent cases
  • Free assistance: Call 1-855-408-1212 for help with forms and process
  • Binding decisions: If approved, Cigna must provide coverage within 3 business days

Eligibility Requirements:

  • State-regulated plan (most commercial plans qualify)
  • Denial based on medical necessity or experimental treatment determination
  • Exhausted internal appeals (unless expedited criteria met)
From our advocates: In our experience helping patients with specialty drug appeals in North Carolina, having an infectious disease specialist provide a detailed letter explaining why Cresemba is specifically needed—rather than just saying other treatments "failed"—significantly improves success rates in both internal and external reviews.

Renewal Cycles & Reauthorization

Planning for Reauthorization

Cigna typically approves Cresemba for 6-month periods, requiring reauthorization for continued therapy.

Submit Renewal 30 Days Early:

  • Updated clinical status and imaging
  • Treatment response documentation
  • Continued specialist oversight
  • Any changes in diagnosis or comorbidities

Factors That Speed Renewals:

  • Documented clinical improvement
  • No significant adverse events
  • Ongoing infectious disease management
  • Clear treatment endpoint plan

Timeline Visual & Milestones

Phase Timeline Key Actions Expected Outcome
Preparation 0-2 days Gather documents, verify benefits Ready to submit
Submission Day 1 Electronic PA submission Confirmation received
Initial Review 1-5 days Cigna clinical review Approval or info request
Additional Info 1-7 days Respond to requests Decision issued
Internal Appeal 30-60 days If denied, file appeal Overturn or uphold
External Review 45 days (standard) Smart NC review Binding decision

Time-Saving Tips for Faster Approval

Portal Optimization

  • Use electronic submission: CoverMyMeds or EviCore for fastest processing
  • Complete all fields: Incomplete forms trigger automatic delays
  • Upload attachments: Include all supporting documents in initial submission

Clinical Documentation Best Practices

  • Lead with diagnosis: Clear ICD-10 codes in first paragraph
  • Address step therapy upfront: For aspergillosis, explicitly document voriconazole trial
  • Include specialist support: Infectious disease consultation strengthens cases
  • Cite guidelines: Reference IDSA or other professional society recommendations

Communication Strategies

  • Mark urgent when appropriate: Life-threatening infections qualify for expedited review
  • Follow up proactively: Check status after 3 business days
  • Prepare for peer-to-peer: Have prescriber available for clinical discussion

For complex cases or repeated denials, Counterforce Health offers specialized support in creating targeted appeals that address payer-specific criteria and procedural requirements, potentially reducing the time from denial to approval.

FAQ

Q: How long does Cigna prior authorization take for Cresemba in North Carolina? A: Standard review is 2-5 business days with complete documentation. Expedited review for urgent cases takes 24-72 hours.

Q: Is step therapy required for all Cresemba indications? A: No. Step therapy with voriconazole is required for invasive aspergillosis but not for invasive mucormycosis.

Q: Can I request an expedited appeal in North Carolina? A: Yes. Both Cigna internal appeals and Smart NC external review offer expedited options for urgent medical situations.

Q: What if my employer plan is self-funded? A: Self-funded ERISA plans may not be subject to North Carolina's external review process. Check with Smart NC at 1-855-408-1212 to confirm eligibility.

Q: Does Cresemba require specialty pharmacy dispensing? A: Most Cigna plans require Cresemba to be dispensed through Accredo or Express Scripts specialty pharmacy network.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and clinical circumstances. For personalized guidance, consult with your healthcare provider and insurance representative. North Carolina residents can access free insurance assistance through Smart NC at 1-855-408-1212.

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