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

How to Get Acthar Gel Covered by Cigna in Michigan: Prior Authorization, Appeals, and Formulary Alternatives Guide

Answer Box: Getting Acthar Gel Covered by Cigna in Michigan

Cigna requires prior authorization and step therapy for Acthar Gel (repository corticotropin injection) in Michigan. You'll need documented failure or contraindication to preferred alternatives like prednisone or IV methylprednisolone. If denied, Michigan gives you 127 days to file an external review with DIFS after exhausting internal appeals. Start today: Have your doctor gather records of prior steroid treatments and submit a prior authorization request through Cigna's provider portal or Express Scripts, documenting medical necessity and treatment failures.

Table of Contents

When Alternatives Make Sense

Before pursuing Acthar Gel coverage, understand that Cigna—like most insurers—requires you to try less expensive alternatives first. This isn't arbitrary: high-dose corticosteroids like IV methylprednisolone and oral prednisone show similar or superior efficacy to Acthar Gel for most conditions, at a fraction of the cost.

Acthar Gel costs over $100,000 per treatment course, while a typical steroid regimen costs under $100. For multiple sclerosis exacerbations, studies show IV methylprednisolone achieves similar outcomes with fewer side effects. The main exception is infantile spasms, where Acthar Gel demonstrates superior response rates (86.7% vs. 28.6% for prednisone).

Alternatives make sense when:

  • Your condition responds well to standard corticosteroids
  • Cost is a significant factor in your treatment plan
  • You haven't yet tried first-line therapies
  • Your insurance requires step therapy compliance

Alternatives may not be appropriate if:

  • You have documented steroid intolerance or contraindications
  • Previous corticosteroid treatments failed after adequate trials
  • You have infantile spasms (where Acthar Gel is often first-line)
  • Specific medical conditions prevent steroid use

Typical Formulary Alternatives

Cigna typically requires trials of these preferred alternatives before approving Acthar Gel:

High-Dose Corticosteroids

  • IV Methylprednisolone: 500-1000 mg daily for 3-7 days (MS exacerbations, severe inflammatory conditions)
  • Oral Prednisone: High-dose regimens, often with taper protocols
  • Prednisolone: Alternative oral steroid, especially for pediatric use

Condition-Specific Alternatives

  • Multiple Sclerosis: IV methylprednisolone remains the gold standard
  • Nephrotic Syndrome: Prednisone is first-line for most types
  • Rheumatologic Conditions: Methotrexate, sulfasalazine, or other DMARDs may be required first

Specialty Alternatives (for refractory cases)

  • IVIG (intravenous immunoglobulin): For certain autoimmune neurologic conditions
  • Rituximab: Anti-CD20 therapy for specific autoimmune diseases
  • Other immunosuppressants: Depending on your specific diagnosis
From our advocates: We've seen cases where patients assumed they needed to fail multiple steroid courses, but often one well-documented trial with clear evidence of inadequate response or intolerance is sufficient for approval—especially when the treating specialist provides detailed clinical rationale.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Acthar Gel prescriptions Cigna Provider Portal
Step Therapy Must try preferred alternatives first Cigna Formulary Documents
Medical Necessity Documented failure/contraindication to alternatives Provider clinical notes
Formulary Status Typically Tier 4 or non-formulary Current year formulary
Appeal Deadline (Internal) 180 days from denial Cigna member materials
External Review (Michigan) 127 days after final internal denial Michigan DIFS

Step-by-Step: Fastest Path to Approval

1. Gather Documentation (Patient + Provider)

Who: You and your doctor
What: Medical records showing prior treatments, dates, doses, and outcomes
Timeline: Before PA submission
Source: Your medical records and pharmacy history

2. Submit Prior Authorization

Who: Your prescribing physician
What: PA form with clinical rationale and supporting documentation
How: Cigna provider portal or Express Scripts system
Timeline: 72 hours for standard review, 24 hours for expedited
Source: Cigna PA Process

3. Request Peer-to-Peer Review (if initially denied)

Who: Your doctor
What: Direct discussion with Cigna medical director
Timeline: Within 24-48 hours of denial
Benefit: Often resolves denials without formal appeal

4. File Internal Appeal

Who: You or your provider (with authorization)
What: Formal appeal with additional evidence
Timeline: Must file within 180 days of denial
Where: Cigna appeals department

5. Request External Review (Michigan)

Who: You (patient)
What: Independent medical review by Michigan DIFS
Timeline: 127 days after final internal denial
Decision: Binding on Cigna if approved
Source: Michigan DIFS External Review

Common Denial Reasons & Solutions

Denial Reason How to Overturn
"Step therapy not completed" Document trials of prednisone/methylprednisolone with dates, doses, duration
"Not medically necessary" Provide specialist consultation notes, treatment guidelines, FDA labeling
"Experimental/investigational" Submit peer-reviewed studies, FDA approval documentation
"Alternative available" Document contraindications or failures of specific alternatives
"Quantity limits exceeded" Justify dosing based on FDA labeling, body weight, or specialist recommendations

Appeals Process in Michigan

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and payer policies to create point-by-point rebuttals using the right clinical evidence and procedural requirements.

Internal Appeals (Cigna)

  • First Level: Submit within 180 days of denial
  • Second Level: If first appeal denied
  • Expedited: Available for urgent medical situations (24-hour decision)

External Review (Michigan DIFS)

Michigan's Patient's Right to Independent Review Act provides strong consumer protections:

  • Timeline: 127 days after final internal denial
  • Process: Submit via DIFS online form or paper application
  • Decision: Within 60 days (standard) or 72 hours (expedited)
  • Cost: Free to patients
  • Contact: DIFS toll-free at 877-999-6442

Expedited External Review requires a physician letter stating that delay would harm the patient's health.

Switching Back to Acthar Gel Later

If you try alternatives but experience treatment failure or relapse, switching back to Acthar Gel requires careful documentation:

What to Document During Alternative Trials

  • Specific medications tried: Names, doses, duration
  • Objective measures: Lab values, symptom scores, functional assessments
  • Side effects or intolerances: Detailed clinical notes
  • Treatment goals not met: Specific outcomes that didn't improve

Provider Coordination

Work with your specialist to:

  • Maintain detailed treatment logs
  • Schedule regular follow-up assessments
  • Document any disease progression or symptom worsening
  • Prepare comprehensive clinical summaries for re-authorization

Studies show that patients may relapse months after initial treatment, making re-authorization common. Having thorough documentation from your alternative therapy trial strengthens future Acthar Gel requests.

Costs & Patient Support

Acthar Gel costs approximately $80,000-$100,000 per treatment course. Patient support options include:

  • Mallinckrodt Patient Support Program: Copay assistance and prior authorization support
  • State pharmaceutical assistance programs: Michigan may have programs for high-cost medications
  • Charitable foundations: Organizations supporting rare disease patients
  • Hospital financial assistance: If receiving treatment as an inpatient

Contact the manufacturer directly for current support program eligibility and applications.

FAQ

How long does Cigna prior authorization take in Michigan?
Standard PA reviews take up to 72 hours. Expedited reviews (for urgent medical situations) are completed within 24 hours.

What if Acthar Gel is non-formulary on my Cigna plan?
You can request a formulary exception. Your doctor must demonstrate that formulary alternatives have been tried and failed, or are contraindicated.

Can I request an expedited appeal in Michigan?
Yes. Both Cigna internal appeals and Michigan DIFS external reviews offer expedited processes when delay could harm your health.

Does step therapy apply if I tried alternatives in another state?
Yes, if you have documentation. Cigna accepts prior treatment records from other states as long as they're properly documented.

What happens if DIFS approves my external review?
The decision is binding on Cigna. They must cover the treatment as directed by the independent medical review.

How do I get help with the appeals process?
Contact Michigan DIFS at 877-999-6442 for free assistance. Counterforce Health also provides specialized support for complex prior authorization and appeals processes.

What clinical evidence works best for Acthar Gel appeals?
Specialist consultation notes, documented steroid failures, FDA labeling supporting your specific indication, and peer-reviewed studies showing efficacy for your condition.

Can my doctor appeal on my behalf?
Yes, with your written authorization. Many providers are experienced with Cigna's appeal process and can submit more clinically detailed appeals.

This article provides educational information about insurance coverage processes and is not medical advice. Consult your healthcare provider for medical decisions. For assistance with Michigan insurance appeals, contact the Department of Insurance and Financial Services at 877-999-6442 or visit michigan.gov/difs.

Sources & Further Reading

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