By Counterforce Health Team in Alecensa (alectinib) —

How to Get Alecensa (Alectinib) Covered by Cigna in Ohio: Complete Prior Authorization Guide

Answer Box: Getting Alecensa (Alectinib) Covered by Cigna in Ohio

Fastest path to approval: Submit Cigna's prior authorization form with ALK-positive test results, complete diagnosis documentation, and medical necessity letter citing NCCN guidelines. If denied, you have 180 days for internal appeal and 120 days for Ohio external review. First step today: Gather your ALK test results and contact your oncologist to initiate the PA request through Cigna's provider portal.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria for Approval
  4. Documentation Requirements
  5. Submission Process
  6. Specialty Pharmacy Requirements
  7. After Submission: What to Expect
  8. Appeals Process in Ohio
  9. Common Denial Reasons & Solutions
  10. Cost Assistance Programs
  11. Frequently Asked Questions

Who Should Use This Guide

This guide is for Ohio residents with Cigna coverage who need Alecensa (alectinib) for ALK-positive non-small cell lung cancer (NSCLC). You'll find this helpful if:

  • Your doctor prescribed Alecensa and you're starting the prior authorization process
  • Cigna denied your initial request and you need to appeal
  • You're considering switching from another ALK inhibitor
  • You need adjuvant therapy after lung cancer surgery

Expected outcome: With complete documentation, most medically appropriate requests are approved within 7-14 days. Appeals have a strong success rate when proper clinical evidence is provided.

Member & Plan Basics

Coverage Requirements

  • Active Cigna coverage with prescription benefits
  • Prior authorization required for all Alecensa prescriptions
  • Specialty pharmacy dispensing through Accredo (Cigna's preferred specialty pharmacy)
  • Medical necessity must align with FDA labeling and NCCN guidelines

Plan Types That Cover Alecensa

  • Cigna commercial plans (employer-sponsored)
  • Individual marketplace plans
  • Some Medicare Advantage plans (check your specific formulary)
Note: Self-funded employer plans may have different criteria. Check your Summary Plan Description or contact member services at the number on your insurance card.

Clinical Criteria for Approval

According to Cigna's Alecensa coverage policy, approval requires:

Primary Requirements

  • Age: 18 years or older
  • Diagnosis: ALK-positive non-small cell lung cancer
  • ALK testing: Confirmed by FDA-approved diagnostic test
  • Disease stage: Advanced/metastatic OR adjuvant post-surgical resection

Specific Indications

Metastatic NSCLC:

  • ALK-positive disease by approved test
  • Advanced or metastatic stage
  • Approval duration: Up to 1 year

Adjuvant NSCLC:

  • ALK-positive disease
  • Tumor ≥4 cm or node-positive
  • Complete surgical resection
  • Approval duration: Up to 2 years

Step Therapy Considerations

Cigna follows NCCN guidelines that list Alecensa as a preferred first-line treatment for ALK-positive NSCLC. Step therapy through other ALK inhibitors is typically not required, but document any prior treatments attempted.

Documentation Requirements

Essential Clinical Documents

  1. ALK test results from FDA-approved diagnostic
  2. Pathology report confirming NSCLC diagnosis
  3. Staging information (CT scans, PET scans)
  4. Medical necessity letter from prescribing oncologist
  5. Prior treatment history (if applicable)

Medical Necessity Letter Components

Your oncologist's letter should include:

  • Patient demographics and diagnosis with ICD-10 codes (C34.xx series)
  • ALK-positive status with test method and results
  • Disease staging and extent
  • Treatment rationale citing NCCN guidelines
  • Dosing plan (typically 600 mg twice daily with food)
  • Monitoring plan for liver function and CPK levels

ICD-10 Coding

Use specific lung cancer codes:

  • C34.10: Malignant neoplasm of upper lobe, unspecified bronchus or lung
  • C34.30: Malignant neoplasm of lower lobe, unspecified bronchus or lung
  • C34.80: Malignant neoplasm of overlapping sites of unspecified bronchus or lung

Submission Process

Step-by-Step Submission

  1. Complete Cigna's PA form (available through provider portal)
  2. Attach all required documentation listed above
  3. Submit via provider portal or fax to specialty pharmacy team
  4. Include NDC number: 50242-0130-01 (150mg capsules)
  5. Request expedited review if clinically urgent

Submission Channels

  • Provider portal: Cigna Provider Portal
  • Phone: Contact Cigna provider services for assistance
  • Fax: Use number provided in denial letter or portal
Tip: Always request confirmation of receipt and note the reference number for tracking.

Specialty Pharmacy Requirements

Accredo Specialty Pharmacy

Cigna requires Alecensa to be dispensed through Accredo, their specialty pharmacy partner.

After PA approval:

  1. Your doctor sends prescription to Accredo
  2. Accredo contacts you to set up delivery
  3. First shipment typically arrives within 3-5 business days
  4. Ongoing refills coordinated automatically

Accredo Contact: 1-800-803-2523

Transfer Process

If you have an existing prescription elsewhere:

  1. Call Accredo to initiate transfer
  2. Provide current pharmacy information
  3. Confirm delivery address and preferences
  4. Verify insurance coverage and copay

After Submission: What to Expect

Timeline Expectations

  • Standard review: 7-14 business days
  • Expedited review: 24-72 hours (for urgent cases)
  • Additional information requests: May extend timeline by 5-10 days

Status Tracking

  • Check status through Cigna provider or member portal
  • Call member services with your reference number
  • Your prescribing physician will receive notification

What to Record

  • PA reference number
  • Submission date and method
  • Contact person (if applicable)
  • Expected decision timeline

Appeals Process in Ohio

Internal Appeal Timeline

If Cigna denies your request, you have 180 calendar days from the denial notice to file an internal appeal.

Appeal Submission Requirements

  1. Written appeal request with denial letter
  2. Additional medical evidence addressing denial reasons
  3. Updated medical necessity letter from your oncologist
  4. Peer-to-peer review request (if available)

Ohio External Review Process

After internal appeal denial, Ohio residents can request external review through an Independent Review Organization (IRO).

Key Details:

  • Deadline: 120 days from final internal denial
  • Process: Managed by Ohio Department of Insurance
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Binding decision: IRO decision is final and binding on Cigna

Contact Ohio Department of Insurance:

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Missing ALK test Submit FDA-approved test results Pathology report with ALK status
Insufficient staging Provide complete staging workup CT/PET scans, staging summary
Step therapy required Document medical necessity for first-line use NCCN guideline citations
Prior treatment not documented Submit treatment history Previous therapy records, response data
Dosing concerns Clarify appropriate dosing rationale Weight-based calculations, monitoring plan

Strengthening Your Appeal

When appealing, Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals by identifying the specific denial basis and drafting point-by-point rebuttals aligned with the plan's own coverage rules.

Cost Assistance Programs

Genentech Patient Assistance

  • Copay program: May reduce out-of-pocket costs for eligible patients
  • Patient assistance program: Free medication for qualifying uninsured/underinsured patients
  • Contact: Genentech Access Solutions

Additional Resources

  • CancerCare: Financial assistance and copay help
  • Patient Advocate Foundation: Copay relief program
  • Pharmaceutical Research and Manufacturers of America (PhRMA): Medicine assistance tool

Frequently Asked Questions

Q: How long does Cigna prior authorization take for Alecensa in Ohio? A: Standard reviews take 7-14 business days. Expedited reviews for urgent cases are completed within 24-72 hours.

Q: What if Alecensa isn't on Cigna's formulary? A: You can request a formulary exception with medical necessity documentation. Alecensa is typically covered as a specialty medication with prior authorization.

Q: Can I request an expedited appeal in Ohio? A: Yes, if delays would seriously jeopardize your health. Both Cigna internal appeals and Ohio external reviews offer expedited pathways.

Q: Does step therapy apply if I've tried other ALK inhibitors outside Ohio? A: Treatment history from any location should be documented. Cigna's policy recognizes prior therapy regardless of where it was received.

Q: What happens if my appeal is denied? A: After exhausting Cigna's internal appeals, you can request external review through Ohio's Independent Review Organization process within 120 days.

Q: How much does Alecensa cost without insurance? A: The wholesale acquisition cost is approximately $19,466 per 240-count bottle, but patient assistance programs can significantly reduce out-of-pocket expenses.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan and clinical circumstances. Always consult with your healthcare provider and insurance representative for personalized guidance. Counterforce Health provides specialized support for navigating complex prior authorization and appeals processes.

From our advocates: "We've seen many Ohio patients successfully obtain Alecensa coverage by ensuring their ALK test results are clearly documented and their oncologist's medical necessity letter directly addresses Cigna's specific coverage criteria. The key is matching your clinical documentation to the exact requirements in their policy—this simple alignment often makes the difference between approval and denial."

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.