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

How to Get Acthar Gel Covered by Cigna in Illinois: Complete Forms, Appeals, and Approval Guide

Answer Box: Getting Acthar Gel Covered by Cigna in Illinois

Cigna requires prior authorization for Acthar Gel with strict step therapy requirements. In Illinois, you have 180 days to file internal appeals and 4 months for external review after final denial. First step today: Download Cigna's drug-specific PA form, document failed corticosteroid trials, and submit via CoverMyMeds for fastest processing. For non-infantile spasm cases, Cortrophin trial is required before Acthar approval.

Table of Contents

  1. Start Here: Verify Your Plan and Coverage
  2. Required Forms and Documentation
  3. Submission Portals and Electronic Options
  4. Fax and Mail Backup Options
  5. Express Scripts Specialty Pharmacy Process
  6. Support Lines and Contact Numbers
  7. Illinois Appeals and External Review
  8. Common Denial Reasons and Solutions
  9. When to Escalate to State Regulators

Start Here: Verify Your Plan and Coverage

Before starting the approval process, confirm your Cigna plan details and Acthar Gel's coverage status:

Check Your Benefits:

  • Log into myCigna to view your formulary tier for Acthar Gel
  • Verify if Express Scripts manages your specialty pharmacy benefits
  • Confirm your plan type (commercial, Medicare, Medicaid) as requirements vary

Coverage at a Glance:

Requirement Details Source
Prior Authorization Required for all indications Cigna PA Policy
Formulary Status Specialty tier, non-preferred PA Forms Listing
Step Therapy Cortrophin required (except infantile spasms) 2024 PA Criteria
Specialist Requirement Must be prescribed by/with relevant specialist Coverage Policy
Quantity Limits Standard dosing ranges enforced PA Form

Required Forms and Documentation

Primary Form: Download the Acthar Gel Vial CCRD Prior Authorization Form from Cigna's official forms library.

Key Form Sections Include:

  • Patient demographics and Cigna ID
  • Prescriber specialty, NPI, and contact information
  • Diagnosis selection from approved list:
    • Infantile spasms
    • Multiple sclerosis exacerbations
    • Rheumatoid arthritis
    • Lupus nephritis
    • Sarcoidosis
    • Nephrotic syndrome
    • Other FDA-approved indications

Clinical Documentation Checklist

Required for All Cases:

  • Specialist consultation documentation
  • Complete diagnostic workup with ICD-10 codes
  • Current medication list and dosing rationale
  • Treatment goals and monitoring plan

Step Therapy Documentation (Non-Infantile Spasms):

  • Systemic corticosteroid trial: drug, dose, duration, outcome
  • Specific failure reason: lack of efficacy, severe adverse effects, contraindications
  • Cortrophin trial: dose, duration, response or intolerance details
  • Supporting clinic notes and hospital records
Clinician Corner: Illinois continuity laws may protect existing Acthar users from mid-year formulary changes. Document current therapy start date and clinical response when submitting renewals.

Submission Portals and Electronic Options

Fastest Electronic Submission:

  1. CoverMyMeds (Recommended)
  2. SureScripts ePA
    • Integrated into most EHR systems
    • Attach clinic notes, labs, and imaging directly from patient chart
    • Automatic routing to Cigna review team
  3. Express Scripts Specialty Portal
    • MyAccredoPatients.com for prescribers
    • Submit electronic referral with embedded PA
    • Upload medical records via iAssist platform

Portal Access Requirements:

  • Provider NPI registration
  • Practice tax ID verification
  • Secure login credentials

Fax and Mail Backup Options

When Electronic Submission Isn't Available:

Fax Submission:

  • Fax number printed on current PA form (varies by line of business)
  • Include completed form as first page
  • Attach all supporting documentation
  • Use cover sheet with patient name and Cigna ID

Mail Address: Check your specific denial letter or PA form for current mailing address, as these can vary by plan type and region.

Cover Sheet Tips:

  • Mark "URGENT" if expedited review needed
  • Include prescriber contact number for questions
  • Number all pages sequentially

Express Scripts Specialty Pharmacy Process

Accredo Coordination: Most Cigna plans use Accredo Specialty Pharmacy for Acthar Gel dispensing.

Step-by-Step Specialty Pharmacy Setup:

  1. PA Approval First: Accredo cannot fill without valid Cigna PA approval
  2. Prescription Routing: Send prescription to Accredo after PA approval
  3. Patient Enrollment: Accredo contacts patient for intake and insurance verification
  4. Clinical Support: Specialty pharmacists provide ongoing adherence monitoring
  5. Delivery Coordination: Temperature-controlled shipping to patient or clinic

Accredo Contact:

Counterforce Health helps patients and clinicians navigate complex specialty drug approvals by turning insurance denials into targeted, evidence-backed appeals. Our platform identifies denial reasons and drafts point-by-point rebuttals aligned to each plan's specific criteria, significantly improving approval rates for medications like Acthar Gel.

Support Lines and Contact Numbers

Cigna Member Services:

  • General Line: 1-800-668-3813 (TTY 711)
  • Hours: Oct 1-Mar 31: 8am-8pm daily; Apr 1-Sep 30: 8am-8pm Mon-Fri
  • Services: Coverage verification, PA status, appeals assistance

Provider Support:

  • PA Assistance: 1-800-882-4462
  • Services: Expedited processing, clinical consultation, peer-to-peer review requests

Accredo Case Management:

  • Phone: 1-877-826-7657
  • Services: Prescription transfers, coverage verification, clinical support

What to Ask When You Call

For Members:

  • "What's the status of PA request #[number]?"
  • "What documentation is missing from my Acthar Gel request?"
  • "Can I request expedited review for medical urgency?"

For Providers:

  • "I need to request a peer-to-peer review for denied Acthar Gel PA"
  • "What specific step therapy documentation is required?"
  • "Can you expedite this request due to clinical urgency?"

Illinois Appeals and External Review

Illinois provides strong patient protection rights for insurance denials through state-supervised external review.

Internal Appeals Process

Timeline:

  • File within: 180 days of denial date
  • Cigna response: 15 business days (24 hours if expedited)
  • Required: Must complete before external review

How to File:

  • Submit via myCigna portal or mail
  • Include clinical support letter from prescriber
  • Attach documentation addressing specific denial reasons

Illinois External Review

Eligibility: After final internal appeal denial involving medical necessity, experimental treatment, or rescission

Deadline: 4 months from final adverse determination date (shorter than many states)

Process:

  1. Complete Illinois Request for External Review form
  2. Attach Cigna denial letters and supporting medical records
  3. Submit to [email protected]
  4. Independent Review Organization (IRO) assigned
  5. Decision within 45 days (72 hours if expedited)

Key Advantage: IRO decision is binding on Cigna - if overturned, coverage must be provided

Illinois Consumer Assistance

Office of Consumer Health Insurance (OCHI):

  • Helpline: 877-527-9431
  • Services: Appeal assistance, external review guidance, form completion help
  • External Review Questions: 877-850-4740

Illinois Attorney General Health Care Bureau:

  • Helpline: 1-877-305-5145
  • Services: Informal intervention with insurers, complex appeal assistance

Common Denial Reasons and Solutions

Denial Reason Required Documentation How to Fix
"Step therapy not completed" Cortrophin trial documentation Submit detailed notes on Cortrophin dose, duration, and failure/intolerance reason
"Insufficient medical necessity" Complete diagnostic workup Provide specialist consultation notes, diagnostic imaging, lab results confirming diagnosis
"Alternative therapies not tried" Corticosteroid failure documentation Document specific steroid trials with doses, duration, and adverse effects
"Prescriber not qualified" Specialist consultation Obtain referral to/consultation with neurologist, rheumatologist, or nephrologist as appropriate
"Dosing outside guidelines" Clinical justification Provide literature support and detailed rationale for atypical dosing

Appeals Strategy for Acthar Gel

Strengthen Your Case:

  • Include peer-reviewed literature supporting Acthar Gel's unique mechanism
  • Document patient-specific contraindications to standard therapies
  • Provide quality of life assessments showing functional improvement needs
  • Reference FDA labeling for your specific indication

Common Successful Arguments:

  • ACTH's distinct immunomodulatory effects beyond corticosteroids
  • Patient's inability to tolerate high-dose systemic steroids
  • Failure of multiple conventional immunosuppressants
  • Specialist recommendation based on disease severity

When to Escalate to State Regulators

Contact Illinois Department of Insurance if:

  • Cigna fails to respond within required timeframes
  • PA criteria seem inconsistent with medical evidence
  • Appeals process appears compromised
  • External review decision is not implemented

Illinois DOI Consumer Division:

Documentation to Include:

  • Complete timeline of PA requests and appeals
  • All denial letters and correspondence
  • Clinical documentation supporting medical necessity
  • Evidence of procedural violations or delays
From Our Advocates: We've seen Illinois external reviews succeed when providers include specific documentation of why Acthar Gel's unique ACTH mechanism is medically necessary versus corticosteroids alone. The key is connecting clinical evidence to the patient's individual treatment failures and specialist recommendations.

FAQ

How long does Cigna PA take for Acthar Gel in Illinois? Standard review: 72 hours for step therapy exceptions, up to 15 business days for complex cases. Expedited review: 24 hours if medical urgency is documented.

What if Acthar Gel is non-formulary on my plan? Request a formulary exception through the same PA process. Provide clinical justification for why formulary alternatives are inappropriate for your specific condition.

Can I request expedited appeal if denied? Yes, if delay would seriously jeopardize your health. Your physician must certify medical urgency in writing when submitting the expedited appeal request.

Does step therapy apply if I failed treatments in another state? Yes, but document all prior therapy failures regardless of where they occurred. Illinois continuity laws may provide additional protections for existing therapy.

What's the success rate for Acthar Gel appeals in Illinois? While specific rates aren't published, Counterforce Health data shows well-documented appeals addressing step therapy requirements have significantly higher approval rates.

How much does external review cost in Illinois? External review is free for consumers. The Illinois Department of Insurance covers all IRO costs.

Update Cadence

Check These Resources Quarterly:

Annual Reviews:

  • Illinois PA statistics reports
  • Plan formulary changes (typically January)
  • State insurance law modifications

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Always consult with your healthcare provider about treatment decisions and verify current requirements with Cigna and Illinois regulators.

Sources & Further Reading

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