By Counterforce Health Team in Acthar Gel (repository corticotropin injection) —

How to Get Acthar Gel Covered by Cigna in California: Complete Prior Authorization and Appeal Guide

Answer Box: Get Acthar Gel Covered by Cigna in California

Cigna requires prior authorization for Acthar Gel (repository corticotropin injection) with mandatory step therapy through systemic corticosteroids and Cortrophin for most conditions except infantile spasms and acute MS exacerbations. California residents have strong appeal rights through the state's Independent Medical Review (IMR) process, which overturns specialty drug denials at a 60-70% success rate. First step today: Have your doctor submit a Cigna PA request with documentation of prior corticosteroid failure/intolerance. If denied, file an internal appeal, then request California IMR through the DMHC.

Table of Contents

  1. Coverage at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Understanding What Drives Acthar Gel Costs
  4. Benefit Investigation: What to Ask Cigna
  5. Assistance Options: Copay Cards and Financial Aid
  6. Common Denial Reasons & How to Fix Them
  7. Appeals Playbook for California
  8. Pharmacy Choice: Accredo vs. Retail
  9. Scripts & Templates for Success
  10. FAQ

Coverage at a Glance

Requirement What it means Where to find it Source
Prior Authorization Required for all indications Cigna PA forms Cigna Policy
Formulary Tier Tier 4/5 (Specialty) - highest cost-sharing 2025 Cigna Formulary Cigna Formulary
Step Therapy Corticosteroids + Cortrophin required first Coverage Policy IP_0178 Cigna Policy
Specialist Required Neurologist, nephrologist, or rheumatologist Coverage Policy IP_0178 Cigna Policy
Age Limits Under 2 years for infantile spasms Coverage Policy IP_0178 Cigna Policy
California Appeals IMR available after internal appeal DMHC Help Center California DMHC

Step-by-Step: Fastest Path to Approval

  1. Gather Documentation (Patient/Clinic)
    • Complete medical records showing diagnosis
    • Documentation of prior corticosteroid trials and outcomes
    • Evidence of Cortrophin trial (except for infantile spasms/acute MS)
    • Timeline: 1-2 days
  2. Specialist Consultation (Patient)
    • See neurologist, nephrologist, or rheumatologist
    • Get written support for Acthar Gel necessity
    • Timeline: 1-2 weeks (depending on availability)
  3. Submit PA Request (Clinic)
    • Complete Cigna PA forms
    • Include all supporting documentation
    • Submit via CoverMyMeds, SureScripts, or fax
    • Timeline: Same day submission
  4. Await Decision (Patient)
    • Standard review: 72 hours for urgent, 15 days for routine
    • Expedited available for urgent medical situations
    • Timeline: 1-15 days
  5. If Denied: Internal Appeal (Patient/Clinic)
    • File within 180 days of denial
    • Include additional evidence, peer-reviewed studies
    • Request peer-to-peer review if needed
    • Timeline: 30 days for decision
  6. If Still Denied: California IMR (Patient)
    • File with DMHC within 6 months
    • Free process with 60-70% success rate for specialty drugs
    • Timeline: 45 days standard, 7 days expedited
  7. Enroll in Patient Support (Patient)
    • Contact Acthar Support at 1-888-435-2284
    • Apply for copay assistance if commercially insured
    • Timeline: 1-3 days
Tip: California's IMR process is particularly favorable for specialty drugs like Acthar Gel. Don't give up after an initial denial—the state's independent review has overturned many similar cases.

Understanding What Drives Acthar Gel Costs

Acthar Gel is one of the most expensive prescription drugs in the U.S., with each 5 mL vial costing approximately $36,000-$45,000. The typical annual treatment requires 7-8 vials, bringing total costs to around $300,000-$318,000 per patient.

Why Cigna Restricts Coverage:

  • High acquisition cost compared to standard corticosteroids
  • Limited comparative effectiveness data versus alternatives
  • Step therapy protocols designed to try lower-cost options first
  • Specialty tier placement (Tier 4/5) with highest patient cost-sharing

Benefit Design Impact: Your out-of-pocket costs depend on your specific Cigna plan's specialty drug coverage. Even with insurance, coinsurance of 20-40% on a Tier 4/5 drug can mean thousands in annual costs without additional assistance.

Benefit Investigation: What to Ask Cigna

Before starting the PA process, gather this essential information by calling Cigna member services:

Coverage Questions:

  • "Is Acthar Gel on my plan's formulary, and what tier?"
  • "What's my specialty drug coinsurance percentage?"
  • "Is there an annual out-of-pocket maximum for specialty drugs?"
  • "Which pharmacy must I use—Accredo or can I choose?"

PA Process Questions:

  • "What specific forms are required for Acthar Gel PA?"
  • "How long does the review process typically take?"
  • "Can I request expedited review for urgent cases?"
  • "What documentation is required beyond the prescription?"

Information to Record:

  • Reference number for each call
  • Representative name and date
  • Specific policy numbers mentioned
  • Any special requirements for your diagnosis

Assistance Options: Copay Cards and Financial Aid

Manufacturer Support

Acthar Gel Commercial Co-pay Program:

  • Reduces costs to as little as $0 per prescription
  • Up to $15,000 annual assistance for commercially insured patients
  • Eligibility: Must have commercial insurance (not Medicare/Medicaid)
  • How to apply: Contact Acthar Support at 1-888-435-2284
Note: Federal law prohibits copay assistance for government insurance programs including Medicare, Medicaid, and TRICARE.

Foundation Grants

For patients who don't qualify for manufacturer assistance:

  • Patient Advocate Foundation
  • National Organization for Rare Disorders (NORD)
  • HealthWell Foundation
  • Individual disease-specific foundations

Specialty Pharmacy Benefits

When using Cigna's required specialty pharmacy (typically Accredo):

  • Negotiated discounts reduce acquisition costs
  • Coordination with manufacturer programs
  • Clinical support and monitoring services
  • Home delivery and injection training if needed

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Step therapy not completed" Prove corticosteroid failure/intolerance Medical records showing adverse effects, lack of efficacy, or contraindications
"Not medically necessary" Provide clinical evidence Peer-reviewed studies, FDA labeling, specialty guidelines
"Experimental/investigational" Show FDA approval for indication FDA label, clinical practice guidelines
"Quantity exceeds limits" Justify dosing based on patient factors Weight-based calculations, specialist recommendations
"Not prescribed by specialist" Get specialist involvement Consultation notes from neurologist, nephrologist, or rheumatologist

Key Documentation for Appeals:

  • Complete diagnosis with ICD-10 codes
  • Chronological treatment history
  • Evidence of prior therapy failures
  • Current clinical status and treatment goals
  • Published literature supporting use

Appeals Playbook for California

California offers some of the strongest patient appeal rights in the nation through the Department of Managed Health Care (DMHC).

Internal Appeals with Cigna

Timeline: Must file within 180 days of denial Process:

  1. Call Cigna appeals department
  2. Submit written appeal with new evidence
  3. Request peer-to-peer review if clinical
  4. Await decision within 30 days (72 hours if urgent)

California Independent Medical Review (IMR)

When to Use: After exhausting internal appeals Success Rate: 60-70% for specialty drugs like Acthar Gel Cost: Free to patients

How to File:

  1. Visit DMHC website or call 888-466-2219
  2. Complete IMR application online or by mail
  3. Include all medical records and denial letters
  4. DMHC assigns to independent medical experts

Timeline:

  • Standard IMR: 45 days maximum
  • Expedited IMR: 7 days (urgent cases)
  • Decision is binding on Cigna
From our advocates: We've seen many California patients successfully overturn Acthar Gel denials through IMR, particularly when the appeal includes current clinical guidelines and evidence that standard treatments have failed. The key is thorough documentation of the medical necessity and specialist support for the treatment plan.

Pharmacy Choice: Accredo vs. Retail

Cigna Requirement: Most Cigna plans mandate use of Accredo specialty pharmacy for Acthar Gel coverage.

Why Accredo is Required:

  • Negotiated pricing reduces plan costs
  • Specialized handling of high-cost biologics
  • Clinical monitoring and support services
  • Coordination with manufacturer assistance programs

Retail Pharmacy Issues:

  • Claims often denied without specialty pharmacy coordination
  • Cash prices exceed $40,000 per vial
  • Limited experience with complex specialty drugs
  • No access to manufacturer rebates

Working with Accredo:

  • Prescription automatically transferred from retail pharmacies
  • Home delivery with temperature control
  • Clinical pharmacist consultations available
  • Coordination with copay assistance programs

Scripts & Templates for Success

Patient Script for Calling Cigna

"Hi, I'm calling about prior authorization for Acthar Gel, also called repository corticotropin injection. My doctor wants to prescribe this for [condition], and I need to understand your coverage requirements. Can you tell me what documentation is needed and how long the review process takes?"

Clinic Script for Peer-to-Peer Review

"I'm requesting a peer-to-peer review for my patient who was denied Acthar Gel coverage. This patient has failed multiple corticosteroid trials with documented adverse effects, and current clinical guidelines support Acthar Gel as appropriate therapy. When can we schedule the clinical review?"

Medical Necessity Letter Template

Your specialist should include these elements:

  • Patient diagnosis with ICD-10 codes
  • Complete history of prior treatments tried
  • Specific reasons why alternatives failed or are contraindicated
  • Clinical rationale for Acthar Gel based on published guidelines
  • Expected treatment duration and monitoring plan

FAQ

How long does Cigna PA take in California? Standard PA decisions are made within 15 days, while urgent requests are processed within 72 hours. The timeline starts when Cigna receives complete documentation.

What if Acthar Gel is non-formulary on my plan? You can request a formulary exception with clinical justification. If denied, California's IMR process provides strong appeal rights with high success rates for specialty drugs.

Can I request an expedited appeal in California? Yes, both Cigna internal appeals and California IMR offer expedited processes for urgent medical situations, typically decided within 72 hours to 7 days.

Does step therapy apply if I've failed corticosteroids outside California? Yes, documented treatment failures from other states count toward step therapy requirements. Ensure your medical records clearly document the trials and outcomes.

What's the difference between DMHC and CDI in California? DMHC regulates most HMOs and managed care plans (including most Cigna plans), while CDI regulates traditional insurance policies. Most Californians with Cigna fall under DMHC jurisdiction.

How much will Acthar Gel cost with Cigna coverage? Costs vary by plan, but specialty tier drugs typically have 20-40% coinsurance. With manufacturer copay assistance (if eligible), costs can be reduced to $0-$50 per prescription.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned to each payer's specific requirements, significantly improving approval rates for complex specialty medications like Acthar Gel.

For additional support navigating Cigna's PA process or preparing appeals, Counterforce Health provides specialized assistance for California patients facing coverage challenges with high-cost specialty drugs.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider about treatment decisions and contact California insurance regulators or qualified advocates for specific coverage disputes. Coverage policies and requirements may change—verify current information with Cigna and California regulatory agencies.

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