By Counterforce Health Team in Elelyso (taliglucerase alfa) —

How Long Does It Take to Get Elelyso (taliglucerase alfa) Approved by Cigna in Washington? Complete Timeline Guide

Answer Box: Getting Elelyso Approved by Cigna in Washington

Cigna typically decides on Elelyso (taliglucerase alfa) prior authorization requests within 1-3 business days when submitted electronically with complete documentation. Washington state requires insurers to respond within 3 calendar days for standard requests. Your fastest path: (1) Ensure your specialist has confirmed Type 1 Gaucher disease diagnosis with enzyme/genetic testing, (2) Submit PA electronically via CoverMyMeds or Accredo portal with all required clinical documentation, (3) If denied, file internal appeal within 180 days—many denials are overturned with proper evidence.

Table of Contents

  1. What Affects Elelyso 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: Appeal Timeline
  7. Renewal Cycles
  8. Timeline Visual Summary
  9. Time-Saving Tips
  10. Common Denial Reasons & Solutions
  11. Appeals Playbook for Washington
  12. FAQ

What Affects Elelyso Approval Timing

Several factors influence how quickly Cigna approves Elelyso (taliglucerase alfa) for Gaucher disease in Washington:

Benefit Type & Plan Structure

  • Commercial plans through Express Scripts/Accredo: typically 1-3 business days
  • Medicare Advantage: may require additional clinical review, extending to 5-7 days
  • Self-funded employer plans: follow similar timelines but may have custom criteria

Complexity of Medical Criteria Elelyso requires prior authorization due to its high cost (~$839-899 per 200-unit vial) and specific indications. Cigna's coverage policy requires:

  • Confirmed Type 1 Gaucher disease diagnosis
  • Age 4 years or older
  • Specialist prescriber (hematologist, geneticist, or endocrinologist)
  • Documentation of medical necessity

Completeness of Documentation Incomplete submissions are the #1 cause of delays. Missing enzyme assay results, genetic testing, or prior therapy documentation can add 3-7 days to the process.

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist

Diagnosis Confirmation

  • Enzyme assay showing low glucocerebrosidase activity
  • Genetic testing results (if available)
  • Clinical notes from specialist confirming Type 1 Gaucher disease

Prescriber Requirements

  • Board certification in hematology, genetics, or endocrinology
  • Current medical license verification
  • DEA number and NPI

Clinical Documentation

  • Current lab values (CBC, liver function tests)
  • Imaging studies showing organomegaly (if applicable)
  • Functional assessment and symptom documentation
  • Prior therapy history and outcomes

Insurance Information

  • Cigna member ID and group number
  • Prescription benefit details
  • Confirmation of specialty pharmacy network (typically Accredo)
Tip: Gather all documentation before starting the PA process. Incomplete submissions can delay approval by up to a week.

Submission to Initial Review (1-5 Days)

Washington State Requirements

Washington requires insurers to respond to standard electronic prior authorization requests within 3 calendar days. This applies to all carriers operating in the state, including Cigna.

Submission Methods (Fastest to Slowest)

  1. Electronic Platforms (1-2 days)
    • CoverMyMeds - real-time processing
    • Accredo Provider Portal - integrated with Cigna systems
    • Surescripts through EHR - automated routing
  2. Fax Submission (2-3 days)
    • Cigna specialty pharmacy PA fax line
    • Manual review process
  3. Phone/Mail (3-5 days)
    • Not recommended for routine requests

What Reviewers Check First

Cigna's clinical team reviews requests in this order:

  1. Patient eligibility and benefit verification
  2. Prescriber credentials and specialty
  3. Diagnosis confirmation (ICD-10 code E75.22)
  4. Medical necessity criteria alignment
  5. Step therapy requirements (if applicable)

Additional Information Requests (1-7 Days)

If Cigna requests additional information, you'll receive notification within 24-48 hours of submission. Common requests include:

Clinical Clarifications

  • Updated enzyme levels or genetic testing
  • Specialist consultation notes
  • Treatment response documentation

Administrative Details

  • Prescriber credential verification
  • Dosing rationale (standard is 60 U/kg every 2 weeks)
  • Site of care justification

How to Respond Quickly

  • Submit within 14 days to avoid automatic denial
  • Use the same electronic platform for consistency
  • Include a cover letter addressing each specific request
  • Contact Counterforce Health for assistance with complex appeals documentation

Decision Window & Outcomes

Typical Approval Timeline

Submission Method Initial Review Additional Info Final Decision
Electronic (complete) 1-2 days N/A 1-2 days
Electronic (incomplete) 1-2 days 3-7 days 4-9 days
Fax/Phone 2-3 days 3-7 days 5-10 days

Reading Your Approval Letter

Full Approval

  • Authorization number provided
  • Quantity and refill limits specified
  • Valid dates clearly stated
  • Accredo contact information included

Conditional Approval

  • May require step therapy completion
  • Dosing modifications required
  • Additional monitoring specified

Denial

  • Specific reason codes listed
  • Appeal rights and deadlines provided
  • Required documentation for appeal outlined

If Denied: Appeal Timeline

Internal Appeal Process

Filing Deadline: 180 days from denial date Cigna Response Time: 30 days (standard) or 72 hours (urgent)

Required Documentation:

  • Written appeal letter addressing denial reasons
  • Updated clinical evidence
  • Specialist letter supporting medical necessity
  • Peer-reviewed literature (when applicable)

External Review (Washington State)

If Cigna upholds the denial, Washington residents can request external review through an Independent Review Organization (IRO).

Filing Deadline: 120 days from final internal denial IRO Decision Time: 15-20 days (standard) or 72 hours (expedited) Cost: Free to patients

Contact the Washington Office of Insurance Commissioner at 1-800-562-6900 for assistance.

Renewal Cycles

Elelyso authorizations typically require renewal every 6-12 months. Renewal reviews focus on:

  • Treatment response documentation
  • Continued medical necessity
  • Dosing appropriateness
  • Adverse event monitoring

Time-Saving Renewal Tips:

  • Submit renewal requests 30-45 days before expiration
  • Include updated clinical assessments
  • Document treatment benefits and goals achieved

Timeline Visual Summary

Day 0: Submit PA request electronically
Day 1-2: Initial Cigna review
Day 3: Washington state deadline for response
Day 4-7: Additional info period (if needed)
Day 8-10: Final decision
Day 180: Internal appeal deadline
Day 300: External review deadline

Time-Saving Tips

  1. Use Electronic Portals: Submit through CoverMyMeds or Accredo for fastest processing
  2. Bundle Evidence: Include all required documentation in initial submission
  3. Specialist Routing: Ensure requests come from qualified specialists
  4. Template Letters: Use standardized medical necessity templates
  5. Track Deadlines: Set calendar reminders for renewal dates
  6. Portal Monitoring: Check PA status daily through provider portals
From Our Advocates: "We've seen Elelyso approvals expedited significantly when the initial submission includes comprehensive enzyme testing results, clear treatment history, and a detailed specialist letter. One Washington patient received approval in just 24 hours after their hematologist submitted everything electronically through CoverMyMeds with complete documentation."

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Lack of medical necessity Specialist letter with clinical rationale Updated clinical notes, functional assessments
Insufficient diagnosis proof Submit enzyme/genetic testing Lab results, genetic counselor report
Prescriber not specialist Transfer to qualified provider Board certification, specialist consultation
Step therapy requirement Request medical exception Prior therapy failure documentation
Dosing concerns Justify current regimen Weight-based calculations, FDA labeling

Appeals Playbook for Washington

Level 1: Internal Appeal

  • Deadline: 180 days from denial
  • Method: Written appeal via Cigna member portal or mail
  • Timeline: 30 days for decision
  • Success Rate: Approximately 30-40% of well-documented appeals succeed

Level 2: External Review

  • Deadline: 120 days from final internal denial
  • Method: Request through Washington OIC or directly with insurer
  • Timeline: 15-20 days for decision
  • Binding: Yes, if overturned, Cigna must provide coverage

Expedited Reviews

Available when delay could seriously jeopardize health:

  • Internal: 72 hours
  • External: 72 hours
  • Documentation: Physician attestation of urgency required

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, identifying specific coverage criteria, and crafting evidence-backed rebuttals that align with each plan's requirements.

FAQ

How long does Cigna prior authorization take for Elelyso in Washington? Standard electronic submissions are typically approved within 1-3 business days when complete. Washington state law requires responses within 3 calendar days.

What if Elelyso is non-formulary on my Cigna plan? You can request a formulary exception by demonstrating medical necessity and providing clinical evidence that preferred alternatives are inappropriate.

Can I request an expedited appeal for Elelyso? Yes, if delay in treatment could seriously jeopardize your health. Your physician must provide written attestation of urgency.

Does step therapy apply if I've used other Gaucher treatments outside Washington? Yes, prior therapy history from any location counts toward step therapy requirements. Provide complete documentation of previous treatments and outcomes.

What happens if I miss the appeal deadline? Missing deadlines can void your appeal rights. Contact the Washington Insurance Commissioner immediately for guidance on potential options.

How much does external review cost in Washington? External review through Washington's IRO process is free to patients. The insurer pays all costs.

Can my regular doctor prescribe Elelyso? Cigna typically requires a specialist (hematologist, geneticist, or endocrinologist) to prescribe Elelyso for Gaucher disease.

What if Cigna takes longer than 3 days to respond? Contact Cigna immediately and file a complaint with the Washington Insurance Commissioner if the delay continues beyond state requirements.

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. Always consult with your healthcare provider and insurance plan for specific guidance.

Sources & Further Reading:

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.