By Counterforce Health Team in Alecensa (alectinib) —

How to Get Alecensa (alectinib) Covered by Cigna in California: Forms, Appeals, and Contact Numbers

Quick Answer: Getting Alecensa (alectinib) Covered by Cigna in California

Your doctor must submit a prior authorization request with ALK-positive test results and complete clinical documentation. In California, Cigna has 72 hours to respond to non-urgent requests (24 hours for urgent cases). If denied, you can appeal internally through Cigna, then escalate to California's Independent Medical Review (IMR) for a binding external decision. Start today: Ask your oncologist to download Cigna's Alecensa prior authorization form and submit via the Cigna provider portal or fax to 1-866-873-8279.

Table of Contents

Verify Your Plan & Find the Right Forms

Before starting the approval process, confirm your specific Cigna plan type and coverage details. Cigna manages most specialty drugs like Alecensa through Express Scripts or Accredo specialty pharmacy, but your exact requirements depend on your plan.

Check your Cigna ID card for these details:

  • Plan type (HMO, PPO, Medicare Advantage)
  • Member ID and group number
  • Specialty pharmacy information
Tip: If your ID starts with "G," use the specialized phone line at 1-866-494-2111 for faster service.

Most Cigna plans in California require prior authorization for Alecensa, classified as a Tier 4 specialty medication. The current Cigna Prior Authorization Policy for Alecensa outlines specific medical necessity criteria that must be met.

Required Forms & Documentation

Core Prior Authorization Requirements

Your oncologist must provide comprehensive documentation proving medical necessity. Here's what Cigna requires:

Essential Clinical Documentation:

  • ALK testing results showing positive ALK rearrangement (FISH, NGS, or other approved methodology)
  • Pathology report confirming non-small cell lung cancer diagnosis
  • Staging documentation (CT, PET, or brain MRI evidence)
  • Complete treatment history including prior systemic therapies and outcomes
  • Performance status assessment (ECOG score)

For Adjuvant Use After Surgery:

  • Surgical pathology proving complete tumor resection (R0)
  • Postoperative staging via imaging reports
  • Prior adjuvant chemotherapy history, if applicable

Medical Necessity Letter Checklist

Your doctor's letter should address these key points:

  • Patient's specific diagnosis with ICD-10 codes
  • ALK-positive status with testing methodology
  • Clinical rationale for Alecensa over alternatives
  • Previous treatments tried and reasons for failure/intolerance
  • Expected treatment duration and monitoring plan
  • Citations to NCCN guidelines or FDA labeling

Submission Portals & Methods

Electronic Submission (Fastest)

Primary Options:

  • Cigna for Health Care Professionals - Main provider portal
  • CoverMyMeds - Widely used for specialty drug PAs
  • ExpressPAth - Express Scripts' dedicated PA platform
  • MyAccredoPatients - For Accredo specialty pharmacy coordination

Required Provider Information

Your doctor will need:

  • Active Cigna provider credentials
  • Patient's complete insurance information
  • Access to upload supporting documents (labs, pathology, imaging)
Note: Only healthcare providers can submit prior authorization requests. Patients cannot submit directly.

Fax Numbers & Mailing Addresses

Prior Authorization Submissions

  • Main PA Fax: 1-866-873-8279
  • Provider Support: 1-800-882-4462

Formulary Exceptions & Step Therapy Overrides

  • California Exception Requests Fax: 1-866-649-8173
  • Phone: 1-800-244-6224

Mailing Address (if required)

Cigna Healthcare
Prior Authorization Department
(Address varies by plan - confirm with member services)

Specialty Pharmacy Setup

Once approved, Alecensa will typically be dispensed through Accredo Specialty Pharmacy. Here's how the process works:

Accredo Onboarding Steps

  1. Provider coordination - Your doctor's office works with Accredo to transfer the prescription
  2. Benefits verification - Accredo confirms your coverage and copay
  3. Patient enrollment - You'll receive a welcome call to set up delivery
  4. Ongoing support - Dedicated pharmacists and nurses for questions

Accredo Contact Information

  • Provider line: 877-826-7657
  • Patient services: Available through MyAccredoPatients portal
  • Prior authorization support: Integrated with Cigna's approval process

Support Phone Numbers

For Patients

Service Phone Number Hours
General Member Services 1-800-244-6224 24/7
Medical Management 1-800-882-4462 Business hours
Cancer Support Program 1-800-615-2909 Mon-Fri, 8am-6pm
Cards starting with "G" 1-866-494-2111 Business hours

For Healthcare Providers

  • Prior authorization status: 1-800-882-4462
  • Peer-to-peer review requests: Same number
  • Case management: 1-800-882-4462
From our advocates: When calling Cigna, have your member ID, authorization reference number, and specific questions ready. Representatives can often provide real-time status updates and clarify missing documentation requirements, which can save days in the approval process.

California Appeals & External Review

California offers robust patient protections if Cigna denies your Alecensa request. The state has two regulatory agencies that can help:

Internal Appeals with Cigna

Timeline: File within 180 days of denial Process: Submit additional clinical evidence and request reconsideration Response time: 72 hours for urgent, 30 days for standard

Independent Medical Review (IMR)

If Cigna upholds their denial, California residents can request an Independent Medical Review through the Department of Managed Health Care (DMHC).

Key Benefits:

  • No cost to patients
  • Binding decision - Cigna must comply if IMR rules in your favor
  • High success rate for medically necessary treatments
  • Fast timeline - 45 days for standard, 7 days for urgent

How to File an IMR

  1. Complete Cigna's internal appeal (or skip if urgent)
  2. Download the IMR application from DMHC website
  3. Submit within 6 months of Cigna's final denial
  4. Include supporting documents - denial letters, medical records, doctor's support

DMHC Contact Information:

  • Help Center: 1-888-466-2219
  • Fax: 916-255-5241
  • Online: healthhelp.ca.gov

Common Denial Reasons & Solutions

Denial Reason Required Documentation How to Fix
Missing ALK test ALK-positive results Submit pathology report with testing methodology
Insufficient staging Complete staging workup Provide CT, PET, or brain MRI reports
Step therapy not met Prior treatment failures Document crizotinib trial or contraindications
Adjuvant use questions Surgical history Include operative report and R0 resection confirmation
Medical necessity unclear Clinical rationale Enhanced provider letter with NCCN citations

Step Therapy Override Strategy

If Cigna requires you to try crizotinib first, your doctor can request an override by documenting:

  • Clinical contraindications to crizotinib
  • Previous failure or intolerance to ALK inhibitors
  • Urgent clinical circumstances requiring immediate Alecensa access

Cost Assistance Programs

Even with insurance approval, Alecensa can be expensive. Here are financial assistance options:

Manufacturer Support

  • Genentech Patient Foundation - Provides free medication for eligible patients
  • Copay assistance - May reduce out-of-pocket costs to $5-25 per month
  • Eligibility: Income and insurance requirements apply

California-Specific Programs

  • Medi-Cal coverage if you qualify for California Medicaid
  • Covered California plans with essential health benefits
  • County health programs for uninsured residents

Nonprofit Organizations

Several cancer-focused foundations provide grants for specialty medications. Your oncology team or Cigna's Cancer Support Program can provide referrals.

Frequently Asked Questions

How long does Cigna prior authorization take in California?
Standard requests: 72 hours. Urgent requests: 24 hours. California law requires these timelines, and late responses are considered automatic approvals.

What if Alecensa isn't on my formulary?
Request a formulary exception using Cigna's exception form. Your doctor must provide clinical justification for why formulary alternatives won't work.

Can I get expedited approval?
Yes, if delay would seriously jeopardize your health. Your doctor must certify urgency and provide supporting clinical documentation.

What happens if my appeal is denied?
California residents can request an Independent Medical Review (IMR) for a binding external decision. The IMR process is free and has a high success rate for medically necessary treatments.

Does Cigna cover both metastatic and adjuvant Alecensa use?
Yes, but adjuvant use requires additional documentation including surgical pathology proving complete resection (R0) and appropriate staging.

How do I check my prior authorization status?
Log into myCigna.com or call 1-800-882-4462. Have your member ID and authorization reference number ready.

When to Get Help

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed responses. Their platform identifies specific denial reasons and drafts point-by-point rebuttals using FDA labeling, peer-reviewed studies, and payer-specific requirements—exactly what's needed for complex specialty drug approvals like Alecensa.

If you're facing repeated denials or complex clinical circumstances, consider professional appeal assistance. Many patients and providers find that expert help significantly improves approval rates, especially for high-cost specialty medications.

Additional California Resources:

  • DMHC Help Center: 1-888-466-2219
  • Health Consumer Alliance: Nonprofit patient advocacy
  • Legal aid organizations: For complex coverage disputes

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult your healthcare provider and insurance company for specific coverage decisions. For official California insurance regulations and consumer protections, visit the Department of Managed Health Care or California Department of Insurance.

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