By Counterforce Health Team in Abecma (idecabtagene vicleucel) —

How to Get Abecma (CAR-T Therapy) Covered by Cigna in Washington: Complete Appeals Guide with State Protections

Answer Box: Getting Abecma Covered by Cigna in Washington

Abecma (idecabtagene vicleucel) requires prior authorization from Cigna for multiple myeloma patients who've had ≥4 prior therapies. Washington residents have strong appeal rights including binding external review after internal denials. Start today by: 1) Having your oncologist submit PA via EviCore Medical Oncology Pathways with complete treatment history, 2) Request expedited review if delays risk serious harm, 3) If denied, file internal appeal within 180 days citing medical necessity and Washington RCW 48.43.535 external review rights.

Table of Contents

Why Washington State Rules Matter

Washington has some of the strongest patient protections in the country for insurance denials. Unlike many states, Washington requires insurers to provide binding external review for medical necessity disputes and maintains strict timelines for prior authorization decisions.

Key Washington advantages:

  • External review is free and binding on insurers under RCW 48.43.535
  • Step therapy override protections for cancer patients
  • 120-day deadline to request external review (longer than federal minimums)
  • Proactive Office of Insurance Commissioner that helps consumers navigate appeals

These protections apply to fully-insured commercial plans regulated by Washington's Office of Insurance Commissioner. Medicare Advantage and self-funded employer plans (ERISA) follow different rules, which we'll explain below.

Cigna's Prior Authorization Requirements

Abecma requires prior authorization through Cigna's specialty pharmacy management, typically handled by Express Scripts/Accredo and EviCore by Evernorth for oncology medications.

Coverage Criteria for Abecma

Based on Cigna's oncology coverage policies, Abecma is typically approved when:

  • Diagnosis: Relapsed or refractory multiple myeloma
  • Prior therapies: ≥4 prior lines including an immunomodulatory drug (IMiD), proteasome inhibitor, and anti-CD38 antibody
  • Treatment center: Qualified CAR-T center with appropriate monitoring capabilities
  • Patient fitness: Adequate performance status and organ function
  • FDA-approved indication: Must align with current prescribing information
Clinician Corner: Your medical necessity letter should directly address each criterion above with specific dates, drug names, and response/progression documentation. Include NCCN guidelines supporting CAR-T therapy for the patient's specific clinical scenario.

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Submit PA (Day 1)

Who: Clinic staff

2. Provide Complete Documentation (Days 1-3)

Who: Oncologist

  • Treatment history: Dates, regimens, responses, reasons for discontinuation
  • Current status: Disease progression, organ function, fitness for CAR-T
  • Medical necessity: Why Abecma is appropriate now vs. other options
  • Guidelines support: Reference NCCN or ASCO guidelines

3. Request Expedited Review if Urgent (Day 1)

Who: Physician

  • If delay risks "serious jeopardy to life, health, or ability to regain maximum function"
  • Cigna must decide within 72 hours for urgent requests
  • Include physician statement of urgency with clinical rationale

4. Follow Up on Timeline (Day 3-5)

Who: Patient or clinic

  • Standard PA decisions: 72 hours for non-urgent
  • Call Cigna at 1-800-882-4462 to check status
  • Document all interactions with reference numbers

5. If Denied, File Internal Appeal Immediately

Who: Patient with physician support

  • Submit within 180 days of denial notice
  • Include additional clinical evidence addressing denial reasons
  • Request peer-to-peer review with hematologist/oncologist

Washington's Step Therapy Protections

Washington law requires insurers to provide medical exceptions to step therapy when clinically inappropriate. For multiple myeloma patients, common override scenarios include:

Exception Criteria

  • Prior failure: Patient previously tried required drug with progression or intolerance
  • Contraindication: Required drug is medically inappropriate due to comorbidities
  • Disease urgency: Aggressive relapse where delay risks rapid progression
  • Current stability: Patient responding to non-preferred regimen

Documentation for Step Therapy Override

Include this language in your appeal: "Requesting step therapy exception under Washington state law. The required step therapy is not appropriate because [specific clinical reason]. The requested therapy is medically necessary and consistent with current NCCN guidelines for this patient's disease stage and prior treatment history."

External Review & State Complaints Process

If Cigna denies your internal appeal, Washington residents with fully-insured commercial plans can request binding external review.

External Review Process

Step Timeline Action Required
File request Within 120 days of final denial Submit to Washington Office of Insurance Commissioner
IRO assignment 3 business days OIC assigns Independent Review Organization
Submit evidence 5 business days Patient/physician submit additional documentation
IRO decision 15-20 days Binding decision on medical necessity

When External Review Applies

  • Medical necessity disputes (most Abecma denials)
  • Experimental/investigational determinations
  • Coverage interpretation disagreements
  • Step therapy requirement disputes
Important: External review decisions are legally binding on Cigna. If the IRO approves coverage, Cigna must provide the treatment.

Filing External Review

Contact Washington OIC Consumer Advocacy: 1-800-562-6900 or submit online at the OIC consumer portal. Reference RCW 48.43.535 and request independent external review of Cigna's denial.

Appeals Playbook for Cigna Denials

Internal Appeal (First Level)

  • Deadline: 180 days from denial notice
  • Submit to: Address on denial letter or Cigna member portal
  • Include: New clinical evidence, physician letter, guideline citations
  • Timeline: 30 days for standard, 72 hours for urgent

Second-Level Internal Appeal

  • Automatic: If first appeal denied
  • Timeline: 30 days for decision
  • Peer review: Request review by hematologist/oncologist
  • Evidence: Can submit additional documentation

External Review (Washington Only)

  • Eligibility: Fully-insured commercial plans after internal appeals
  • Deadline: 120 days from final internal denial
  • Cost: Free to patient
  • Decision: Binding on Cigna

Common Denial Reasons & How to Fix Them

Denial Reason Fix Strategy Documentation Needed
"Not medically necessary" Provide NCCN guidelines support Treatment history, progression data, guideline excerpts
"Experimental/investigational" Cite FDA approval and standard-of-care status FDA label, peer-reviewed studies, society guidelines
"Insufficient prior therapies" Document all prior lines with dates Pharmacy records, clinic notes, progression imaging
"Not at qualified center" Confirm center certification CAR-T center accreditation documentation

Scripts for Patients and Clinicians

Patient Phone Script for Cigna

"I'm calling about prior authorization for Abecma for multiple myeloma. My reference number is [X]. This is medically necessary treatment recommended by my oncologist. If this is denied, I need information about my appeal rights under Washington state law, including external review under RCW 48.43.535."

Clinician Peer-to-Peer Request

"I'm requesting a peer-to-peer review with a hematologist/oncologist regarding the denial for Abecma. This patient has relapsed/refractory multiple myeloma with [X] prior therapies and meets all NCCN criteria for CAR-T therapy. The denial appears to be inconsistent with current evidence-based guidelines."

ERISA vs. Fully-Insured Plan Differences

Fully-Insured Commercial Plans

  • Washington state protections apply
  • External review available through OIC
  • Step therapy override protections
  • Binding IRO decisions

Self-Funded Employer Plans (ERISA)

  • Federal rules only - Washington protections may not apply
  • No state external review - limited to internal appeals
  • Federal lawsuit option after exhausting internal appeals
  • Check Summary Plan Description to confirm ERISA status

Medicare Advantage

  • Federal Medicare appeals process only
  • No Washington external review
  • CMS reconsideration and ALJ hearing options
  • Different timelines than commercial plans

FAQ

How long does Cigna prior authorization take for Abecma in Washington? Standard PA: 72 hours. Urgent/expedited: 24-72 hours. Internal appeals: 30 days. External review: 15-20 days.

What if Abecma is not on Cigna's formulary? Request formulary exception with medical necessity documentation. Washington's external review process covers formulary disputes for fully-insured plans.

Can I request expedited appeal if my condition is worsening? Yes. If delay would "seriously jeopardize life, health, or ability to regain maximum function," request expedited review at every level.

Does step therapy apply if I failed therapies under a different insurance plan? Document all prior therapies regardless of payer. Washington law supports step therapy overrides based on prior failures under any coverage.

What's the difference between Cigna Medicare Advantage and commercial coverage for Abecma? Medicare Advantage follows federal Medicare rules with different appeal processes. Commercial fully-insured plans have Washington state protections including binding external review.

How do I know if my employer plan is subject to Washington state rules? Check your Summary Plan Description. Self-funded/ERISA plans are governed by federal law. Fully-insured plans must follow Washington state requirements.

Quick Reference Contacts

  • Cigna Prior Authorization: 1-800-882-4462
  • EviCore Medical Oncology: Prior Authorization Portal
  • Washington Office of Insurance Commissioner: 1-800-562-6900
  • Cigna Member Services: Number on insurance card
  • Express Scripts/Accredo: 1-800-753-2851

At Counterforce Health, we help patients, clinicians, and specialty pharmacies navigate complex prior authorization and appeals processes. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that turn insurance denials into approvals. We understand that getting access to life-saving treatments like Abecma shouldn't require patients to become insurance experts – that's why we built tools to level the playing field.

If you're facing a denial for Abecma or other specialty medications, Counterforce Health can help you identify the specific denial basis and draft point-by-point rebuttals aligned to your plan's own rules, complete with the right clinical evidence and procedural requirements for your state and payer.

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. Always consult with your healthcare provider and insurance plan for specific guidance. For personalized help with appeals, contact the Washington Office of Insurance Commissioner at 1-800-562-6900.

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